NSG 333 Ch 20- Nursing Management of the Pregnancy at Risk: Selected Health Conditions and Vulnerable Populations

The nurse is assessing a woman with class III heart disease who is in for a prenatal visit. What would be the first recognizable sign that this client is in heart failure?

persistent rales in the bases of the lungs Explanation: The earliest warning sign of cardiac decompensation is persistent rales (crackles) in the bases of the lungs.

A nurse is conducting a review class for a group of perinatal nurses working at the local clinic. The clinic sees a high population of women who are HIV positive. After discussing the recommendations for antiretroviral therapy with the group, the nurse determines that the teaching was successful when the group identifies which rationale as the underlying principle for the therapy?

reduction in viral loads in the blood Rationale: Drug therapy is the mainstay of treatment and is important in reducing the viral load as much as possible. Antiretroviral agents do not treat opportunistic infections and are not adjunctive therapy. There is no cure for HIV/AIDS.

A pregnant woman with diabetes is having a glycosylated hemoglobin (HgbA1C) level drawn. Which result would require the nurse to revise the client's plan of care?

8.5% Explanation: A glycosylated hemoglobin level of less than 7% indicates good control; a value of more than 8% indicates poor control and warrants intervention. Therefore, the nurse would need to revise the plan of care.

What important instruction should the nurse give a pregnant client with tuberculosis?

Maintain adequate hydration. Explanation: The nurse should instruct the pregnant client with tuberculosis to maintain adequate hydration as a health-promoting activity. The client need not avoid direct sunlight or red meat, or wear light clothes; these have no impact on the client's condition.

A nurse is caring for a pregnant client with heart disease in a labor unit. Which intervention is most important in the first 48 hours postpartum?

assessing for cardiac decompensation Explanation: The nurse should assess the client with heart disease for cardiac decompensation, which is most common from 28 to 32 weeks' gestation and in the first 48 hours postpartum. Limiting sodium intake, inspecting the extremities for edema, and ensuring that the client consumes a high-fiber diet are interventions during pregnancy not in the first 48 hours postpartum.

When preparing a schedule of follow-up visits for a pregnant woman with chronic hypertension, which schedule would be most appropriate?

bi-monthly visits until 28 weeks, then weekly visits Rationale: For the woman with chronic hypertension, antepartum visits typically occur every 2 weeks until 28 weeks' gestation and then weekly to allow for frequent maternal and fetal surveillance.

A pregnant woman with diabetes is having her hemoglobin (glycosylated) level evaluated. The nurse determines that the woman's glucose is under control and continues the woman's plan of care based on which result?

6.5% Explanation: A hemoglobin (glycosylated) level of less than 7% indicates good control; a value of more than 8% indicates poor control and warrants intervention. A glycosylated hemoglobin level less than 7% indicates that the plan is working and should be continued.

A pregnant woman with gestational diabetes comes to the clinic for a fasting blood glucose level. When reviewing the results, the nurse determines that the woman is achieving good glucose control based on which result?

88 mg/dL Rationale: For a pregnant woman with diabetes, the ADA and ACOG recommend maintaining a fasting blood glucose level below 95 mg/dL, with postprandial levels below 140 mg/dL at 1 hour, below 120 mg/dL at 2 hours.

A pregnant client is screened for tuberculosis during her first prenatal visit. An intradermal injection of purified protein derivative (PPD) of the tuberculin bacilli is given. Which sign would indicate a positive test result?

An indurated wheal over 10 mm in diameter appears in 48 to 72 hours. Explanation: A positive PPD result would be an indurated wheal over 10 mm in diameter that appears in 48 to 72 hours. The area must be a raised wheal, not a flat, circumscribed area.

A nurse is providing education to a woman at 28 weeks' gestation who has tested positive for gestational diabetes mellitus (GDM). What would be important for the nurse to include in the client teaching?

She is at increased risk for type 2 diabetes mellitus after her baby is born. Explanation: The woman who develops GDM is at increased risk for developing type 2 diabetes mellitus after pregnancy.

A nurse is teaching a 30-year-old gravida 1 who has sickle cell anemia. Providing education on which topic is the highest nursing priority?

avoidance of infection Explanation: Prevention of crises, if possible, is the focus of treatment for the pregnant woman with sickle cell anemia. Maintaining adequate hydration, avoiding infection, getting adequate rest, and eating a balanced diet are all common-sense strategies that decrease the risk of a crisis. Fat intake does not need to be decreased and immunoglobulins are not normally administered. Constipation is not usually a result of sickle cell anemia.

When teaching a class of pregnant women about the effects of substance use during pregnancy, the nurse would include which effect?

low-birthweight infants Rationale: Substance use during pregnancy is associated with low birth weight infants, preterm labor, abortion, intrauterine growth restriction, abruptio placentae, neurobehavioral abnormalities, and long-term childhood developmental consequences. Excessive weight gain, higher pain tolerance, and longer gestational periods are not associated with substance use.

A woman who has sickle cell anemia asks the nurse if her infant will develop sickle cell disease. The nurse would base the answer on which information?

Sickle cell anemia is recessively inherited. Explanation: Sickle cell anemia is an autosomal recessive disease requiring that the person have two genes for the disease, one from each parent. If one parent has the disease and the other is free of the disease and trait, the chance of the child inheriting the disease is zero. If the woman has the disease and her partner has the trait, there is a 50% chance that the child will be born with the disease. If both parents have the disease, then all of their children also will have the disease.

A 16-year-old girl comes to the public health office and tells the nurse she is pregnant. She is afraid to tell her parents. What is important for a nurse to know in order to properly inform this girl?

community resources for the pregnant teen Explanation: The nurse should be knowledgeable regarding community resources for the pregnant teen. If the nurse refers the teen to another entity, following up to ensure the adolescent receives the services for which she was referred is critical. If she does not refer the teen, the nurse should try to determine the barriers that prevent her from following through with treatment and assist her to work through these barriers to obtain needed services.

A nurse is interviewing a pregnant woman who has come to the clinic for her first prenatal visit. During the interview, the client tells the nurse that she works in a day care center with 2- and 3-year olds. Based on the client's history, the nurse would be alert for the development of which condition?

cytomegalovirus Explanation: The nurse would be alert for the development of cytomegalovirus infection. Pregnant women acquire active disease primarily from sexual contact, blood transfusions, kissing, and contact with children in day care centers. It can also be spread through vertical transmission from mother to child in utero (causing congenital CMV), during birth, or through breastfeeding. Chlamydia, gonorrhea, and toxoplasmosis are not spread through contact with children in day care centers.

A mother is talking to the nurse and is concerned about managing her asthma while she is pregnant. Which response to the nurse's teaching indicates that the woman needs further instruction?

"I need to begin taking allergy shots like my friend to prevent me from having an allergic reaction this spring." Explanation: A pregnant woman with a history of asthma needs to be proactive, taking her inhalers and other asthma medications to prevent an acute asthma attack. She needs to understand that it is far more dangerous to not take the medications and have an asthma attack. She also needs to monitor her peak flow for decreases, be aware of triggers, and avoid them if possible. However, a pregnant woman should never begin allergy shots if she has not been taking them previously, due to the potential of an adverse reaction.

A nurse is talking to a newly pregnant woman who had a mitral valve replacement in the past. Which statement by the client reveals an understanding about the preexisting condition?

"I understand that my fetus and I both are at risk for complications." Explanation: When a woman enters pregnancy with a preexisting condition, both she and her fetus can be at risk of developing complications.

A client who is HIV-positive is in her second trimester and remains asymptomatic. She voices concern about her newborn's risk for the infection. Which statement by the nurse would be most appropriate?

"Antiretroviral medications are available to help reduce the risk of transmission." Rationale: Drug therapy is the mainstay of treatment for pregnant women infected with HIV. The goal of therapy is to reduce the viral load as much as possible; this reduces the risk of transmission to the fetus. Decisions about the method of birth should be based on the woman's viral load, duration of ruptured membranes, progress of labor, and other pertinent clinical factors. The newborn is at risk for HIV because of potential perinatal transmission. Waiting until after the infant is born may be too late.

A woman with a history of systemic lupus erythematosus comes to the clinic for evaluation. The woman tells the nurse that she and her partner would like to have a baby but that they are afraid her lupus will be a problem. Which response would be most appropriate for the nurse to make?

"Be sure that your lupus is stable or in remission for 6 months before getting pregnant." Rationale: The time at which the nurse comes in contact with the woman in her childbearing life cycle will determine the focus of the assessment. If the woman is considering pregnancy, it is recommended that she postpone conception until the disease has been stable or in remission for 6 months. Active disease at time of conception and history of renal disease increase the likelihood of a poor pregnancy outcome (Cunningham et al., 2018). In particular, if pregnancy is planned during periods of inactive or stable disease, the result is often giving birth to healthy full-term babies without increased risks of pregnancy complications. Nonetheless, pregnancies with most autoimmune diseases are still classified as high risk because of the potential for major complications. Preconception counseling should include the medical and obstetric risks of spontaneous abortion, stillbirth, fetal death, fetal growth restriction, preeclampsia, preterm labor, and neonatal death and the need for more frequent visits for monitoring the condition. Treatment of SLE in pregnancy is generally limited to NSAIDs (e.g., ibuprofen), prednisone, and an antimalarial agent, hydroxychloroquine. During pregnancy in the woman with SLE, the goal is to keep drug therapy to a minimum.

The nurse is assessing a newborn of a woman who is suspected of abusing alcohol. Which newborn finding would provide additional evidence to support this suspicion?

thin upper lip Rationale: Newborn characteristics suggesting fetal alcohol spectrum disorder include thin upper lip, small head circumference, small eyes, receding jaw, and short nose. Other features include a low nasal bridge, short palpebral fissures, flat midface, epicanthal folds, and minor ear abnormalities.

A pregnant woman is diagnosed with iron-deficiency anemia and is prescribed an iron supplement. After teaching her about her prescribed iron supplement, which statement indicates successful teaching?

"I need to eat foods high in fiber." Rationale: Iron supplements can lead to constipation, so the woman needs to increase her intake of fluids and high-fiber foods. Milk inhibits absorption and should be discouraged. Vitamin Ccontaining fluids such as orange juice are encouraged because they promote absorption. Ideally the woman should take the iron on an empty stomach to improve absorption, but many women cannot tolerate the gastrointestinal discomfort it causes. In such cases, the woman should take it with meals. Iron typically causes the stool to become black and tarry; there is no need for the woman to notify her primary care provider.

A pregnant client has tested positive for cytomegalovirus. What can this cause in the newborn?

microcephaly Explanation: Signs that are likely to be present in the 10% of newborns who are symptomatic at birth include microcephaly, seizures, IUGR, hepatosplenomegaly, jaundice, and rash.

The nurse is assessing a pregnant client with a known history of congestive heart failure who is in her third trimester. Which assessment findings should the nurse prioritize?

dyspnea, crackles, and irregular weak pulse Explanation: The nurse should be alert for signs of cardiac decompensation due to congestive heart failure, which include crackles in the lungs from fluid, difficulty breathing, and weak pulse from heart exhaustion. The heart rate would not be regular, and a cough would not be dry. The heart rate would increase rather than decrease.

A nursing instructor is teaching students about preexisting illnesses and how they can complicate a pregnancy. The instructor recognizes a need for further education when one of the students makes which statement?

"A pregnant woman does not have to worry about contracting new illnesses during pregnancy." Explanation: When a woman enters a pregnancy with a chronic illness, it can put both her and the fetus at risk. She needs to be cautious about developing a new illness during her pregnancy as well as having an accident during the pregnancy.

A pregnant client is diagnosed with syphilis. Which response would demonstrate respect for the client and therapeutic communication?

"I am sure it is frightening to you to be diagnosed with a disease that can affect your baby." Explanation: The nurse needs to be supportive, empathic and accepting of the client, asking open-ended questions and acting calm and reassuring to her. By acknowledging her fears for her fetus, the nurse is demonstrating respect for her and conveying confidence that the client is trying to take care of her fetus.

A pregnant woman with chronic hypertension is entering her second trimester. The nurse is providing anticipatory guidance to the woman about measures to promote a healthy outcome. The nurse determines that the teaching was successful based on which client statement(s)? Select all that apply.

"I should try to lie down and rest on my left side for about an hour each day." "I will start doing daily counts of my baby's activity at about 24 weeks' gestation." "I should take my blood pressure frequently at home and report any high readings." Rationale: The woman with chronic hypertension will be seen more frequently (every 2 weeks until 28 weeks' gestation and then weekly until birth) to monitor her blood pressure and to assess for any signs of preeclampsia. At approximately 24 weeks' gestation, the woman will be instructed to document fetal movement. At this same time, serial ultrasounds will be prescribed to monitor fetal growth and amniotic fluid volume. The woman should also have daily periods of rest (1 hour) in the left lateral recumbent position to maximize placental perfusion and use home blood pressure monitoring devices frequently (daily checks would be preferred), reporting any elevations.

A pregnant client with iron-deficiency anemia is prescribed an iron supplement. After teaching the woman about using the supplement, the nurse determines that more teaching is needed based on which client statement?

"I will take the iron with milk instead of orange or grapefruit juice." Rationale: The pregnant client should take the iron supplement with vitamin C-containing fluids such as orange juice, which will promote absorption, rather than milk, which can inhibit iron absorption. Taking iron on an empty stomach improves its absorption, but many women cannot tolerate the gastrointestinal discomfort it causes. In such cases, the woman is advised to take it with meals. The woman also needs instruction about adverse effects, which are predominantly gastrointestinal and include gastric discomfort, nausea, vomiting, anorexia, diarrhea, metallic taste, and constipation. Taking the iron supplement with meals and increasing intake of fiber and fluids helps overcome the most common side effects. If the woman misses a dose, she should take a dose as soon as she remembers.

The nurse is teaching a client with gestational diabetes about complications that can occur either following birth or during the birth for the infant. Which statement by the mother indicates that further teaching is needed by the nurse?

"If my blood sugars are elevated, my baby's lungs will mature faster, which is good." Explanation: Elevated blood sugars delay the maturation of fetal lungs, not increase maturation time, resulting in potential respiratory distress in newborns born to mothers with diabetes. Doing fetal movement (kick) counts is standard practice, as is the possibility of an amniocentesis to determine lung maturity during the third trimester. Health care personnel should also prepare the mother for the potential of a cesarean birth if the infant is too large.

A pregnant woman asks the nurse, "I'm a big coffee drinker. Will the caffeine in my coffee hurt my baby?" Which response by the nurse would be most appropriate?

"If you keep your intake to less than 200 mg/day, you should be okay." Rationale: The effect of caffeine intake during pregnancy on fetal growth and development is still unclear. A recent study found that caffeine intake of no more than 200 mg/day during pregnancy does not affect pregnancy duration and the condition of the newborn. Birth defects have not been linked to caffeine consumption, but maternal coffee consumption decreases iron absorption and may increase the risk of anemia during pregnancy. It is not known if there is a correlation between high caffeine intake and miscarriage due to lack of sufficient studies.

The nurse is teaching a pregnant woman with type 1 diabetes about her diet during pregnancy. Which client statement indicates that the nurse's teaching was successful?

"Pregnancy affects insulin production, so I'll need to make adjustments in my diet." Rationale: In pregnancy, placental hormones cause insulin resistance at a level that tends to parallel growth of the fetoplacental unit. Nutritional management focuses on maintaining balanced glucose levels. Thus, the woman will probably need to make adjustments in her diet. Protein needs increase during pregnancy, but this is unrelated to diabetes. Blood glucose monitoring results typically guide therapy.

A woman's baby is HIV positive at birth. She asks the nurse if this means the baby will develop AIDS. Which statement would be the nurse's best answer?

"The antibodies may be those transferred across the placenta; the baby may not develop AIDS." Explanation: Infants born of HIV-positive women test positive for HIV antibodies at birth because these have crossed the placenta. An accurate disease status cannot be determined until the antibodies fade at about 18 months. Testing positive for HIV antibodies does not mean the infant has AIDS. Having a cesarean birth does decrease the risk of transmitting the virus to the infant at birth; it does not prevent the transmission of the disease. HIV antibodies do cross the placenta, which is why babies born of HIV positive mothers are HIV positive.

After teaching a group of nurses working at the women's health clinic about the impact of pregnancy on the older woman, which statement by the group indicates that the teaching was successful?

"Women over age 35 and are pregnant have an increased risk for spontaneous abortions." Rationale: Whether childbearing is delayed by choice or by chance, women starting a family at age 35 or older are not doing so without risk. Women in this age group may already have chronic health conditions that can put the pregnancy at risk. In addition, numerous studies have shown that increasing maternal age is a risk factor for infertility and spontaneous abortions, gestational diabetes, chronic hypertension, postpartum hemorrhage, preeclampsia, preterm labor and birth, multiple pregnancy, genetic disorders and chromosomal abnormalities, placenta previa, fetal growth restriction, low Apgar scores, and surgical births (Dillion et al. 2019). However, even though increased age implies increased complications, most women today who become pregnant after age 34, have healthy pregnancies and healthy newborns. Nursing assessment of the pregnant woman over age 35 is the same as that for any pregnant woman. Women of this age have the same risk for a substance use disorder as any other age group.

A young adult woman comes to the clinic for a routine check-up. During the visit, the woman who works in a day care facility tells the nurse that she and her partner are considering having a baby. "We are concerned that I might be exposed to common childhood illnesses." The woman undergoes testing and finds out that she is not immune from chickenpox. Based on this information, which information would the nurse give to the client?

"You will need to be vaccinated now and wait at least 1 month before getting pregnant." Rationale: Preconception counseling is important for preventing chickenpox (varicella). A major component of counseling involves determining the woman's varicella immunity. Vaccination is the cornerstone of prevention. The vaccine is administered if needed. Varicella vaccine is a live attenuated viral vaccine. It should be administered to all adolescents and adults 13 years of age and older who do not have evidence of varicella immunity. Therefore, the woman should be vaccinated now before she becomes pregnant and then wait at least 1 month before getting pregnant. The varicella vaccine is contraindicated for pregnant women because the effects of the vaccine on the fetus are unknown. There is no need for the woman to quit her job once she is immunized nor does she need to take a leave of abscence during the winter and spring months when the incidence is highest. Chickenpox does occur and is highly contagious. Maternal varicella can be transmitted to the fetus through the placenta, leading to congenital varicella syndrome if the mother is infected during the first half of pregnancy via an ascending aorta.

A client with asthma is confused by her primary care provider continuing her medication while she is pregnant, since she read online the medications can cause birth defects. What is the nurse's best response?

"Your primary care provider will order safe doses of your medication." Explanation: Women should take no medication during pregnancy except that prescribed by their primary care provider. The PCP will work with the mother to ensure the safest amount is given to adequately handle the mother's health issues and not injure the fetus. The PCP must weigh the risks against the benefits for both the mother and her fetus. The nurse should not encourage the client to stop her asthma medication as that may result in the client having an asthma attack, which could result in injury to the fetus or even miscarriage. The nurse should not tell the client a drug will not cause any defects, especially if it is known that it can. That could make the nurse liable for damages. The nurse should inform the PCP of the client's concerns; however, it is more important for the nurse to calm the client's anxiety and offer positive reinforcement that the PCP is working hard to protect the mother and infant from harm.

The nurse reviews the medical record of a woman who has come to the clinic for an evaluation. The client has a history of mitral valve prolapse and is listed as risk class II. During the visit, the woman states, "We want to have a baby, but I know I am at higher risk. But what is my risk, really?" Which response by the nurse would be appropriate?

"Your risk during pregnancy is small, but you should see your cardiologist first before getting pregnant." Rationale: Typically, a woman with class I or II cardiac disease can go through a pregnancy without major complications. For class I disease, there is no detectable increased risk of maternal mortality and no increase or a mild increase in morbidity. For class II disease, there is a small increased risk of maternal mortality or moderate increase in morbidity and cardiac consultation should occur every trimester. It is best to have the woman see her cardiologist before becoming pregnant. A woman with class III disease needs frequent visits with the cardiac care team throughout pregnancy. There is a significantly increased risk of maternal mortality or severe morbidity and cardiologist consult should occur every other month with prenatal care and delivery occurring at an appropriate level hospital. A woman with class IV disease is typically advised to avoid pregnancy.

The nurse is assessing a pregnant client who has a history of heart disease. The nurse will prioritize assessments focusing on the heart during which time frame?

28 to 32 weeks' gestation Explanation: A pregnant woman with heart disease is most vulnerable for cardiac decompensation from 28 to 32 weeks' gestation, just after the blood volume peaks. It would be important to assess the client's heart at each visit; however, the client's heart would be more stressed at this time due to the increased blood volume and identifying a serious situation early provides the best opportunity for treatment and preventing complications.

A nurse is providing care to several pregnant women at different weeks of gestation. The nurse would expect to screen for group B streptococcus infection in the client who is at:

36 weeks' gestation Rationale: Pregnant women between 36 and 37 weeks' gestation should be universally screened for GBS infection during a prenatal visit and if positive, receive appropriate intrapartum antibiotic prophylaxis.

A pregnant woman with type 2 diabetes is scheduled for a laboratory test of glycosylated hemoglobin (HbA1C). What does the nurse tell the client is a normal level for this test?

6% Explanation: The upper normal level of HbA1C is 6% of total hemoglobin.

A client is 33 weeks' pregnant and has had diabetes since age 21. When checking her fasting blood glucose level, which value would indicate the client's disease is controlled?

85 mg/dl Explanation: Recommended fasting blood glucose levels in pregnant clients with diabetes are 60 to 95 mg/dl. A fasting blood glucose level of 45 g/dl is low and may result in symptoms of hypoglycemia. A blood glucose level below 120 mg/dl is recommended for 2-hour postprandial values. A blood glucose level above 136 mg/dl in a pregnant client indicates hyperglycemia.

At 24 weeks' gestation, a client's 1-hour glucose tolerance test is elevated. The nurse explains that, based on this finding, the client will need to take which action?

A 3-hour glucose tolerance test for follow-up Explanation: The 1-hour glucose tolerance test is a screening procedure. If the results are elevated, the client needs a 3-hour glucose tolerance test, which is diagnostic of gestational diabetes. Since this is only a screening test, no treatment for gestational diabetes, such as finger-sticks or insulin, is implemented until the 3-hour glucose tolerance test result determines if the client has gestational diabetes. An HgbA1C level does not rule out diabetes; it monitors average blood glucose level over an extended period of time.

A G4P3 client with a history of controlled asthma is upset her initial prenatal appointment is taking too long, making her late for another appointment. What is the nurse's best response when the client insists she knows how to handle her asthma and needs to leave?

Acknowledge her need to leave but ask her to demonstrate the use of inhaler and peak flow meter before she goes; remind her to take regular medications. Explanation: Management of asthma during pregnancy is very important; the nurse must document that the client has the proper ability to manage her asthma for her health and the health of the fetus. Reminding the client to continue taking her prescribed medication and to monitor her peak flow daily is not enough. It is the nurse's responsibility to know that the client knows how to take her medications. Monitoring the baby's kicks in the second and third trimester is an appropriate action. Scheduling a return appointment to discuss asthma management is not appropriate. She could have an asthma attack between the time the nurse sees her and the time of the return appointment. Noting in the chart that the woman was not counseled does not relieve the nurse of his/her obligation to ensure that the woman knows how to use her inhaler and her peak flow meter.

A woman with cardiac disease at 32 weeks' gestation reports she has been having spells of light-headedness and dizziness every few days. Which instruction should the nurse prioritize?

Decrease activity and rest more often. Explanation: If the client is developing symptoms associated with her heart condition, the first intervention is to monitor activity levels, decrease activity, and treat the symptoms. At 32 weeks' gestation, the suggestion to induce labor is not appropriate, and without knowledge of the type of heart condition one would not recommend an increase of fluids or vitamins. Total bed rest may be required if the symptoms do not resolve with decreased activity.

The nurse encourages a woman with gestational diabetes to maintain an active exercise period during pregnancy. Prior to this exercise period, the nurse would advise her to take which action?

Eat a sustaining-carbohydrate snack. Explanation: Because exercise uses up glucose, women with diabetes should take a sustaining-carbohydrate snack before hard exercise to prevent hypoglycemia.

The nurse is caring for a pregnant client who indicates that she is fond of meat, works with children, and has a pet cat. Which instructions should the nurse give this client to prevent toxoplasmosis? Select all that apply.

Eat meat cooked to 160° F (71° C). Avoid cleaning the cat's litter box. Avoid outdoor activities such as gardening. Explanation: To minimize risk of toxoplasmosis, the nurse should instruct the client to eat meat that has been cooked to an internal temperature of 160° F (71° C) throughout and to avoid cleaning the cat's litter box or performing activities such as gardening. Avoiding children with colds is unreasonable when working with children, and contact with children with colds is not a cause of toxoplasmosis. The cat should be kept indoors to prevent it from hunting and eating birds or rodents.

A G2P1 woman with type 1 diabetes is determined to be at 8 weeks' gestation by her health care provider. The nurse should point out which factor will help the client maintain glycemic control?

Exercise Explanation: The three main facets to glycemic control for the woman with pregestational diabetes are diet, exercise, and insulin. An individual with type 1 diabetes uses insulin and not oral hypoglycemic agents. Vitamin supplements may assist with helping to keep the woman healthy but not necessarily through glycemic control. It will be important for the woman to get enough rest throughout the pregnancy but this will not assist with glycemic control.

The nurse is appraising the laboratory results of a pregnant client who is in her second trimester and notes the following: thyroid stimulating hormone (TSH) slightly elevated, glucose in the urine, complete blood count (CBC) low normal, and normal electrolytes. The nurse prioritizes further testing to rule out which condition?

Gestational diabetes Explanation: Glycosuria, glucose in the urine, may occur normally during pregnancy; however, if it appears in the urine, the client should be sent for testing to rule out gestational diabetes. Preeclampsia, anemia, and hyperthyroidism are not related to glucose nor to renal function. A slightly elevated TSH would indicate possible hypothyroidism instead of hyperthyroidism. Anemia would be indicated by below normal hematocrit. If the client's CBC is low normal than the nurse should monitor future results to ensure the client's counts are not dropping. It would also be appropriate for the nurse to investigate possible dietary issues. Preeclampsia would be best monitored by the blood pressure readings.

A pregnant woman comes to the clinic for her first evaluation. The woman is screened for hepatitis B (HBV) and tests positive. The nurse would anticipate administering which agent?

HBV immune globulin Rationale: If a woman tests positive for HBV, expect to administer HBV immune globulin. The newborn will also receive HBV vaccine within 12 hours of birth. Acyclovir or valacyclovir would be used to treat herpes simplex virus infection.

A nurse is obtaining a medication history from a pregnant client with a history of systemic lupus erythematosus (SLE). Which medication(s) would the nurse expect the woman to report to be currently using? Select all that apply

Ibuprofen Hydroxychloroquine Prednisone Rationale: Treatment of SLE in pregnancy is generally limited to NSAIDs like ibuprofen, prednisone, and an antimalarial agent, hydroxychloroquine. Methotrexate and leflunomide are used to treat rheumatoid arthritis but are contraindicated for use in pregnancy because of the potential for fetal toxicity.

A nurse caring for a pregnant client suspects substance use during pregnancy. What is the priority nursing intervention for this client?

Obtain a urine specimen for a drug screening. Explanation: Substance use during pregnancy is associated with preterm labor, spontaneous abortion (miscarriage), low birth weight, central nervous system and fetal anomalies, and long-term childhood developmental consequences. It is most important to know what the client is taking in order to provide the best care for the client and newborn.

The nurse is assessing a mother who just delivered a 7 lb (3136 g) baby via cesarean delivery. Which assessment finding should the nurse prioritize if the mother has a history of controlled atrial fibrillation?

Jugular distention Explanation: A woman who has a cardiac condition is at increased risk in the postpartum period. The most important nursing action is to monitor for signs of cardiac decompensation. The nurse should monitor for and report jugular distention, clubbing, and slow capillary refill time. If an irregular pulse is noted, compare it to the apical pulse. The abdominal cramps may be related to the uterus involution. The nausea and vomiting and urinary retention may be related to the surgical procedure and not necessarily the cardiac issue.

The nurse is preparing information for a client who has just been diagnosed with gestational diabetes. Which instruction should the nurse prioritize in this information?

Maintain a daily blood glucose log Explanation: Control of the blood glucose throughout the pregnancy is the primary goal to help decrease potential complications to both the mother and fetus. The mother should keep a daily log of her blood glucose levels and bring this log to each visit for the nurse to evaluate. The other choices of reporting possible signs of a UTI and working with a dietitian to plan menus would also be important but would be secondary to the blood glucose control. It would be inappropriate to discuss long-term goals at this time. This would be handled at a later time and would depend on the mother's situation.

A pregnant woman diagnosed with diabetes should be instructed to perform which action?

Notify the primary care provider if unable to eat because of nausea and vomiting. Explanation: During pregnancy, the insulin levels change in response to the production of HPL. The client needs to alert her provider if she is not able to eat or hold down appropriate amounts of nutrition. The client is at risk for episodes of hypoglycemia during the first trimester. She should never discontinue insulin therapy without her provider's directions. The increase of carbohydrates needs to be balanced with protein, and smaller meals would result in hypoglycemia rather than hyperglycemia.

A woman with a history of asthma comes to the clinic for evaluation for pregnancy. The woman's pregnancy test is positive. When reviewing the woman's medication therapy regimen for asthma, which medication would the nurse identify as problematic for the woman now that she is pregnant?

Prednisone Rationale: Oral corticosteroids such as prednisone are not preferred for the long-term treatment of asthma during pregnancy. Inhaled steroids are the choice for maintenance medications to reduce inflammation that leads to bronchospasm. Common ones prescribed include beclomethasone and salmeterol. Rescue agents such as albuterol or ipratropium provide immediate symptomatic relief by reducing acute bronchospasm.

The maternal health nurse is caring for a group of high-risk pregnant clients. Which client condition will the nurse identify as being the highest risk for pregnancy?

Pulmonary hypertension Explanation: Pulmonary hypertension is considered the greatest risk to a pregnancy because of the hypoxia that is associated with the condition. The remaining conditions represent potential cardiac complications that may increase the client's risk in pregnancy; however, these do not present the greatest risk in pregnancy.

A client in her first trimester comes to the clinic for an evaluation. Assessment reveals reports of fatigue, anorexia, and frequent upper respiratory infections. The client's skin is pale and the client is slightly tachycardic. The client also reports drinking about 6 cups of coffee on average each day. A diagnosis of iron-deficiency anemia is suspected. The client is scheduled for laboratory testing and the results are as follows: • Hemoglobin 11.5 g/dL (115 g/L) • Hematocrit 35% (0.35) • Serum iron 32 µg/dL (5.73 µmol/L) • Serum ferritin 90 ng/dL (90 µg/L) Which laboratory finding would the nurse correlate with the suspected diagnosis?

Serum ferritin level Rationale: Laboratory tests for iron-deficiency anemia usually reveal low hemoglobin (less than 11 g/dL or 110 g/L), low hematocrit (less than 35% or 0.35), low serum iron (less than 30 µg/dL or 5.37 µmol/L), microcytic and hypochromic cells, and low serum ferritin (less than 100 ng/dL or 100 µg/L). The client's hemoglobin, hematocrit, and serum iron levels are borderline low normal, but the client's serum ferritin is below 100 ng/dL (100 µg/L), helping to support the diagnosis.

A nurse is caring for a 33-year-old primigravida client who is obese and near the end of their second trimester. The client has a history of prepregnancy obesity, hypertension, and smoking. Complete the following sentence(s) by choosing from the lists of options.

The client is at highest risk for developing gestational diabetes. The nurse provides discharge teaching to reduce the risks of developing this condition. Teaching should include change in lifestyle. Explanation: Gestational diabetes occurs in pregnant clients who do not have a history of diabetes. Blood glucose and urine are monitored closely for changes in blood glucose levels and glucose or ketones in the urine. Gestational diabetes usually resolves a few weeks after childbirth. Obesity places the client at high risk for gestational diabetes. Pregnant clients with class III obesity (BMI ≥40.0) are more than five and one-half more times likely to develop gestational diabetes. The nurse should educate the client about positive lifestyle changes such as diet, exercise, and cessation of smoking. The client is too far into pregnancy to have an ectopic pregnancy. Gestational trophoblastic disease would have been detected before the end of the second trimester. Spontaneous abortion usually occurs in the first trimester. The nurse should encourage cessation of smoking, not to limit smoking. The nurse should encourage the client to maintain activity or increase it, depending on current activity level, during pregnancy, which will help with weight and blood pressure. The nurse would not recommend the client limit exercise during pregnancy; this would place the client at risk for conditions associated with limited mobility such as deep vein thrombosis. There is no reason the client should refrain from having intercourse during pregnancy.

The clinic nurse teaches a client with pregestational type 1 diabetes that maintaining a constant insulin level is very important during pregnancy. The nurse tells the client that the best way to maintain a constant insulin level is to use:

an insulin pump. Explanation: Because a pregnant client will have some periods of relative hyperglycemia and hypoglycemia no matter how carefully the client maintains diet and balances exercise levels, an effective method to keep serum glucose levels constant is to administer insulin with a continuous pump during pregnancy.

A new young mother has tested positive for HIV. When discussing the situation with the client, the nurse should advise the mother that she should avoid which activity?

breastfeeding Explanation: Breastfeeding is a major contributing factor for mother-to-child transmission of HIV. Cesarean birth before the onset of labor and/or rupture of membranes can greatly reduce the chance of transmitting the infection to the infant. Future pregnancies should be discussed and decided on an individual basis. Proper treatment of any open wounds and education should be provided to the mother to ensure she reduces the chance of transmitting HIV to her infant.

A pregnant client with type I diabetes asks the nurse about how to best control her blood sugar while she is pregnant. The best reply would be for the woman to:

check her blood sugars frequently and adjust insulin accordingly. Explanation: The goal for a mother who has type I diabetes mellitus is to keep tight control over her blood sugars throughout the pregnancy. Therefore, she needs to test her blood sugar frequently during the day and make adjustments in the insulin doses she is receiving.

Assessment of a pregnant woman and her fetus reveals tachycardia and hypertension. There is also evidence suggesting vasoconstriction. The nurse would question the woman about use of which substance?

cocaine Rationale: Cocaine use produces vasoconstriction, tachycardia, and hypertension in both the mother and fetus. The effects of marijuana are not yet fully understood. Alcohol ingestion would lead to cognitive and behavioral problems in the newborn. Heroin is a central nervous system depressant.

A pregnant woman with diabetes at 10 weeks' gestation has a glycosylated hemoglobin (HbA1c) level of 13%. At this time the nurse should be most concerned about which possible fetal outcome?

congenital anomalies Rationale: A HbA1c level of 13% indicates poor glucose control. This, in conjunction with the woman being in the first trimester, increases the risk for congenital anomalies in the fetus. Elevated glucose levels are not associated with incompetent cervix, placenta previa, or placental abruption (abruptio placentae).

A nurse is conducting a presentation for a group of pregnant women about measures to prevent toxoplasmosis. The nurse determines that additional teaching is needed when the group identifies which measure as preventive?

cooking all meat to an internal temperature of 125° F (52° C) Rationale: Meats should be cooked to an internal temperature of 160° F (71° C). Other measures to prevent toxoplasmosis include peeling or thoroughly washing all raw fruits and vegetables before eating them, wearing gardening gloves when in contact with outdoor soil, and avoiding the emptying or cleaning of a cat's litter box.

A nurse is preparing a presentation for a group of young adult pregnant women about common infections and their effect on pregnancy. When describing the infections, which infection would the nurse include as the most common congenital and perinatal viral infection in the world?

cytomegalovirus Rationale: Although rubella, hepatitis B, and parovirus B19 can affect pregnant women and their fetuses, cytomegalovirus (CMV) is the most common congenital and perinatal viral infection in the world. CMV is the leading cause of congenital infection, with morbidity and mortality at birth and sequelae. Each year approximately 1% to 7% of pregnant women acquire a primary CMV infection. Of these, about 30% to 40% transmits infection to their fetuses.

A nurse is conducting a program for pregnant women with gestational diabetes about reducing complications. The nurse determines that the teaching was successful when the group identifies which factor as being most important in helping to reduce complications associated with pregnancy and diabetes?

degree of blood glucose control achieved during the pregnancy Rationale: Therapeutic management for the woman with diabetes focuses on tight glucose control, thereby minimizing the risks to the mother, fetus, and neonate. The woman's emotional and psychological status is highly variable and may or may not affect the pregnancy. Evaluating for long-term diabetic complications such as retinopathy or nephropathy, as evidenced by laboratory testing such as BUN levels, is an important aspect of preconception care to ensure that the mother enters the pregnancy in an optimal state.

A 29-year-old client has gestational diabetes. The nurse is teaching her about managing her glucose levels. Which therapy would be most appropriate for this client?

diet Explanation: Clients with gestational diabetes are usually managed by diet alone to control their glucose intolerance. Long-acting insulin usually is not needed for blood glucose control in the client with gestational diabetes. Oral hypoglycemic drugs are usually not given during pregnancy and would not be the first option. Glucagon raises blood glucose and is used to treat hypoglycemic reactions.

After teaching a pregnant woman with iron deficiency anemia about nutrition, the nurse determines that the teaching was successful when the woman identifies which foods as being good sources of iron in her diet? Select all that apply.

dried fruits peanut butter meats Rationale: Foods high in iron include meats, green leafy vegetables, legumes, dried fruits, whole grains, peanut butter, bean dip, whole-wheat fortified breads, and cereals.

A nurse is preparing a teaching program for a group of pregnant women about preventing infections during pregnancy. When describing measures for preventing cytomegalovirus infection, which measure would the nurse include as a priority?

frequent handwashing Rationale: Most women are asymptomatic and do not know they have been exposed to CMV. Prenatal screening for CMV infection is not routinely performed. Since there is no therapy that prevents or treats CMV infections, nurses are responsible for educating and supporting childbearing-age women at risk for CMV infection. Stressing the importance of good handwashing and use of sound hygiene practices can help to reduce transmission of the virus. There is no immunization for CMV. Antibody titer levels would be useful for identifying women at risk for rubella.

A nurse is conducting an in-service presentation to a group of perinatal nurses about sexually transmitted infections and their effect on pregnancy. The nurse determines that the teaching was successful when the group identifies which infection as being responsible for ophthalmia neonatorum?

gonorrhea Rationale: Infection with gonorrhea during pregnancy can cause ophthalmia neonatorum in the newborn from birth through an infected birth canal. Infection with syphilis can cause congenital syphilis in the neonate. Infection with chlamydia can lead to conjunctivitis or pneumonia in the newborn. Exposure to HPV during birth is associated with laryngeal papillomas.

The health care provider of a newly pregnant client determines the woman also has mitral stenosis and will need appropriate therapy. Which medication should the nurse prepare to teach this client to provide her with the best possible care?

heparin Explanation: This client has an increased risk for developing blood clots. If an anticoagulant is required, heparin is the drug of choice as it does not cross the placenta barrier. Warfarin crosses the placenta and may have teratogenic effects. Aspirin is not recommended in this situation. Digoxin is not used to prevent blood clots.

Which changes in pregnancy would the nurse identify as a contributing factor for arterial thrombosis, especially for the woman with atrial fibrillation?

hypercoagulable state Explanation: The nurse should identify that the increased risk of arterial thrombosis in atrial fibrillation is due to the hypercoagulable state of pregnancy. During pregnancy, there is a state of hypercoagulation. This increases the risk of arterial thrombosis in clients having atrial fibrillation and artificial valves. Increased cardiac output and blood volume do not cause arterial thrombosis. Elevation of the diaphragm is due to the uterine distension, and it causes a shift in the QRS axis and is not associated with arterial thrombosis.

A neonate born to a mother who was abusing heroin is exhibiting signs and symptoms of withdrawal. Which signs would the nurse assess? Select all that apply.

hypertonicity excessive sneezing tremors Rationale: Signs and symptoms of withdrawal, or neonatal abstinence syndrome, include: irritability, hypertonicity, excessive and often high-pitched crying, vomiting, diarrhea, feeding disturbances, respiratory distress, disturbed sleeping, excessive sneezing and yawning, nasal stuffiness, diaphoresis, fever, poor sucking, tremors, and seizures.

A nurse is counseling a pregnant woman with rheumatoid arthritis about medications that can be used during pregnancy. The nurse would emphasize the need to avoid which medication at this time?

methotrexate Rationale: Methotrexate is contraindicated during pregnancy. For rheumatoid arthritis, medications are limited to hydroxychloroquine, glucocorticoids, and NSAIDS.

A nursing instructor is teaching students about anemia during pregnancy. Which type of anemia does the instructor teach students is most prevalent during pregnancy?

iron-deficiency anemia Explanation: Iron-deficiency anemia is the most common type in pregnancy. Many woman enter pregnancy with a low iron count because of poor diet, heavy menstrual periods, unwise weight-loss programs, or a combination of these.

A nurse is caring for a pregnant adolescent client, who is in her first trimester, during a visit to the maternal child clinic. Which important area should the nurse address during assessment of the client?

knowledge of child development Explanation: The nurse should address the client's knowledge of child development during assessment of the pregnant adolescent client. The nurse need not address the sexual development of the client or whether sex was consensual. This would not be an opportune time to discuss birth control methods to be used after the pregnancy.

Which change in insulin is most likely to occur in a woman during pregnancy?

less effective than normal Explanation: Somatotropin released by the placenta makes insulin less effective. This is a safeguard against hypoglycemia.

What is the role of the nurse during the preconception counseling of a pregnant client with chronic hypertension?

stressing the positive benefits of a healthy lifestyle Explanation: The nurse should stress the positive benefits of a healthy lifestyle during the preconception counseling of a client with chronic hypertension. The client need not avoid dairy products or increase intake of vitamin D supplements. It may not be advisable for a client with chronic hypertension to exercise without consultation.

A woman with an artificial mitral valve develops heart failure at the 20th week of pregnancy. Which measure would the nurse stress with her during the remainder of the pregnancy?

obtaining enough rest Explanation: As the blood volume doubles during pregnancy, heart failure can occur. The pregnant woman needs to obtain adequate rest to prevent overworking the heart. Fluid may need to be restricted.

The nurse explains to a pregnant client that she will need to take iron during her pregnancy after being diagnosed with iron-deficiency anemia. The nurse suggests that absorption of the supplemental iron can be increased by taking it with which substance?

orange juice Explanation: Anemia is a condition in which the blood is deficient in red blood cells, from an underlying cause. The woman needs to take iron to manufacture enough red blood cells. Taking an iron supplement will help improve her iron levels, and taking iron with foods containing ascorbic acid, such as orange juice, improves the absorption of iron.

A nurse has been invited to speak at a local high school about adolescent pregnancy. When developing the presentation, the nurse would incorporate information related to which aspects? Select all that apply.

peer pressure to become sexually active loss of self-esteem as a major impact Rationale: Adolescent pregnancy has emerged as one of the most significant social problems facing our society. Early pregnancies among adolescents have major health consequences for mothers and their infants. The latest estimates show that approximately 1 million teenagers become pregnant each year in the United States, accounting for 13% of all U.S. births, but the rates have been declining in the last several years. Teen birth rates in the United States have declined but remain high,especially among African American and Hispanic teenagers and adolescents in southern states. The most important impact lies in the psychosocial area as it contributes to a loss of self-esteem, a destruction of life projects, and the maintenance of the circle of poverty. Moreover, about half of all teen pregnancies occur within 6 months of first having sexual intercourse. About one in four teen mothers under age 18 have a second baby within 2 years after the birth of the first baby.

A 40-year-old woman comes to the clinic reporting having missed her period for two months. A pregnancy test is positive. What is she and her fetus at increased risk for?

placental abnormalities Explanation: A woman older than 35 years is more likely to conceive a child with chromosomal abnormalities such as Down syndrome. She is also at higher risk for spontaneous abortion (miscarriage), preeclampsia-eclampsia, gestational diabetes, preterm birth, bleeding and placental abnormalities, and other intrapartum complications.

A primigravida 21-year-old client at 24 weeks' gestation has a 2-year history of HIV. As the nurse explains the various options for delivery, which factor should the nurse point out will influence the decision for a vaginal birth?

the viral load Explanation: A woman who has HIV during pregnancy is at risk for transmitting the infection to the fetus during pregnancy or childbirth and to the newborn while breastfeeding. The type of birth, vaginal or cesarean, depends on several factors, including the woman's viral load, use of ART during pregnancy (not waiting until the birth), length of time membranes have been ruptured, and gestational age (not mother's age). With prenatal ART and prophylactic treatment of the newborn, there is a reduced risk of perinatal HIV transmission. The amniocentesis results would not be a factor in preventing the spread of HIV to the infant and may actually lead to the fetus being infected through the puncture site and bleeding into the amniotic sac.