OB: Chapter 29

Diabetes refers to a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin action, insulin secretion, or both. Over time, diabetes causes significant changes in the microvascular and macrovascular circulations. These complications include: A. Atherosclerosis. B. Retinopathy. C. IUFD. D. Nephropathy. E.Neuropathy. Autonomcs neuropathy.

These structural changes are most likely to affect a variety of systems, including the heart, eyes, kidneys, and nerves. Intrauterine fetal death (stillbirth) remains a major complication of diabetes in pregnancy; however, this is a fetal complication. (A,B,D,E)

An obese pregnant woman with gestational diabetes is learning self-injection of insulin. While evaluating the woman's technique for self-injection, the nurse would recognize that the woman understood the instructions when she: A. washed her hands and put on a pair of clean gloves. B. shook the NPH insulin vial vigorously to fully mix the insulin. C. drew the NPH insulin into her syringe first. D. spread her skin taut and punctured the skin at a 90-degree angle.

washing hands is important but gloves are not necessary for self-injection; vial should be gently rotated, not shaken; regular insulin should be drawn into the syringe first; because she is obese, a 90-degree angle with skin taut is recommended. (D)

When the pregnant diabetic woman experiences hypoglycemia while hospitalized, the nurse should intervene by having the patient: A. Eat six saltine crackers. B. Drink 8 oz of orange juice with 2 tsp of sugar added. C. Drink 4 oz of orange juice followed by 8 oz of milk. D. Eat hard candy or commercial glucose wafers.

Crackers provide carbohydrates in the form of polysaccharides. Orange juice and sugar will increase the blood sugar but not provide a slow-burning carbohydrate to sustain the blood sugar. Milk is a disaccharide and orange juice is a monosaccharide. They will provide an increase in blood sugar but will not sustain the level. Hard candy or commercial glucose wafers provide only monosaccharides.(D)

###What are the potentially fatal complications associated with diabetes? Select all that apply. Neuropathy Nephropathy Atherosclerosis Cardiomyopathy Restrictive lung disease

Diabetes is a condition characterized by high blood sugar. High blood sugar results in damage to the peripheral nerve, which is referred to as neuropathy. Increased workload on the renal system imposed by high blood sugar results in nephropathy. Diabetes also accelerates the process of atherosclerosis. High blood sugar levels do not impair the function of cardiac muscles and lung function. Therefore, diabetes is not associated with cardiomyopathy or restrictive lung disease. (A,B,C)

A woman with gestational diabetes has had little or no experience reading and interpreting glucose levels. She shows the nurse her readings for the past few days. Which one should the nurse tell her indicates a need for adjustment (insulin or sugar)? A. 75 mg/dL before lunch. This is low; better eat now. B. 115 mg/dL 1 hour after lunch. This is a little high; maybe eat a little less next time. C. 115 mg/dL 2 hours after lunch; This is too high; it is time for insulin. D. 60 mg/dL just after waking up from a nap. This is too low; maybe eat a snack before going to sleep.

60 mg/dL after waking from a nap is too low. During hours of sleep glucose levels should not be less than 70 mg/dL. Snacks before sleeping can be helpful. The premeal acceptable range is 65 to 95 mg/dL. The readings 1 hour after a meal should be less than 140 mg/dL. Two hours after eating, the readings should be less than 120 mg/dL. (D)

During her pregnancy, a woman with pregestational diabetes has been monitoring her blood glucose level several times a day. Which of the following levels would require further assessment? A. 85 mg/dL—before breakfast B. 90 mg/dL—before lunch C. 135 mg/dL—2 hours after supper D. 126 mg/dL—1 hour after breakfast

A 2-hour postprandial blood glucose should be less than 120 mg/dL; choices a, b, and d all fall within the expected normal ranges. (C)

In which pregnant client does the nurse identify the need to screen for undiagnosed homozygous maternal phenylketonuria (PKU)? A. A client who had a macrosomic fetus in a previous pregnancy B. A client who had obstructed labor in a previous pregnancy C. A client who has given birth to a microcephalic infant D. A patient who had placental insufficiency in a previous pregnancy

A client who has previously had a microcephalic infant must be screened for undiagnosed homozygous maternal PKU in the first prenatal visit. Toxic accumulation of phenylalanine in the blood due to a lack of the enzyme phenylalanine hydrolase interferes with brain development. The client who had a previous macrosomic fetus must be screened for hyperglycemia. A client with a macrosomic fetus may have obstructed labor. Placental insufficiency may lead to stillbirth. The client who had placental insufficiency in a previous pregnancy need not be screened for PKU. (C)

The nurse finds that the blood pH of a pregnant client who is diabetic is 6.5. What should the nurse administer to normalize the client's blood pH? A. Dextrose solution B. Normal saline solution C. Sodium citrate solution D. Sodium bicarbonate solution

A blood pH of 6.5 indicates that the client has acidosis. In order to revert this state, the nurse should administer an alkaline solution, such as sodium bicarbonate solution. Dextrose and normal saline solution are neither acidic nor alkaline. These solutions would not help to normalize the blood pH. Sodium citrate solution would increase acidity and would worsen the client's condition. (D)

The nurse is teaching a client diagnosed with phenylketonuria (PKU) about foods to be avoided in the daily diet. Which foods can have an adverse effect on the mother and fetus? Select all that apply. A. Milk B. Eggs C. Nuts D. Fruits E. Vegetables

A client diagnosed with PKU must avoid milk, eggs, and nuts in her diet before conception and throughout the pregnancy. The client must have a modified diet that excludes all high-protein foods. The client lacks the enzyme phenylalanine hydrolase; this lack impairs her body's ability to metabolize the amino acid phenylalanine, found in all protein foods. Most fruits and vegetables contain very little or no proteins; the client may include these in her diet. (A,B,C)

Which manifestation does the nurse relate to hypoglycemia in a diabetic client? A. Clammy skin B. Rapid breathing C. Nausea or vomiting D. Increased urination

A client with hypoglycemia experiences sweating, pallor, and clammy skin. The hypoglycemic client has shallow respirations, whereas the hyperglycemic client takes rapid breaths. Hyperglycemia causes nausea and vomiting. The client with hypoglycemia experiences hunger. In cases of hyperglycemia, the kidneys excrete large volumes of urine in an attempt to regulate excess vascular volume. (A)

A pregnant client with pregestational insulin-dependent diabetes is going for a week's vacation to another state. What should the nurse ask the client to carry with her in order to prevent complications? Select all that apply. A. Antibiotics B. Insulin vials C. Glucose tablets D. Antihypertensives E. Blood glucose meter

A client with pregestational diabetes should be very careful and should be prepared to tackle any complications associated with high or low blood sugar levels. The nurse should ask the client to carry the routine insulin medications. Hormonal effects of pregnancy can also cause hypoglycemia, which can be normalized by taking glucose tablets. The client should be able to find out her blood sugar levels any time. Therefore, the nurse should ask the client to take a glucometer for routine monitoring of blood sugar levels. Antibiotics should be taken only if the client has an infection. Antihypertensives would be required if the client has high blood pressure. (B,C,E)

A nurse is working with a pregestational diabetic woman to plan the diet she will follow during pregnancy. Which of the following nutritional guidelines should be used to ensure a euglycemic state and appropriate weight gain? (Circle all that apply.) A. Substantial bedtime snack composed of complex carbohydrates with some protein and fat B. Average calories per day of 2200 during the first trimester and 2500 during the second and third trimesters C. Caloric distribution among three meals and one or two snacks D. Minimum of 45% carbohydrate daily E. Protein intake of at least 30% of the total kilocalories in a day F. Fat intake of 30% to 40% of the daily caloric intake

A minimum of intake of 55% carbohydrates, 20% protein, and 25% fat is recommended daily (A,B,C)

The nurse providing care for a woman with gestational diabetes understands that a laboratory test for glycosylated hemoglobin Alc: A. Is now done for all pregnant women, not just those with or likely to have diabetes. B. Is a snapshot of glucose control at the moment. C. Would be considered evidence of good diabetes control with a result of 5% to 6%. D. Is done on the patient's urine, not her blood.

A score of 5% to 6% indicates good control. This is an extra test for diabetic women, not one done for all pregnant women. This test defines glycemic control over the previous 4 to 6 weeks. Glycosylated hemoglobin level tests are done on the blood. (C)

A nurse is working with a diabetic patient who recently found out she is pregnant. In coordinating an interdisciplinary team to help manage the patient throughout the pregnancy, the nurse would include: (Select all that apply.) A. Family practice physician B. Dietician C. Perinatologist D. Occupational therapist E. Nephrologist F. Speech therapist

An internal medicine practitioner rather than family practice physician would be included on the interdisciplinary care team. A dietician would be included to help the patient with dietary planning, a perinatologist to take care of the maternal-fetal unit, and a nephrologist to monitor renal function. There is no need for an occupational therapist or a speech therapist unless other issues arise. (B,C,E)

The nurse is caring for a pregnant client with type 2 diabetes. What does the nurse teach the client about glucose metabolism in the first trimester? A. Maternal glucose levels are affected by nausea and cravings. B. The client's insulin dose may need to be increased to prevent hyperglycemia. C. The fetus will produce insulin in the fifth week of gestation. D. The client's fasting blood glucose level will increase.

Dietary fluctuations in early pregnancy due to nausea, vomiting, and cravings affect maternal glycemic control. These fluctuations may result in reduced blood glucose levels. The nurse reminds the client that her insulin dose may need to be decreased to prevent hypoglycemia. The fetus begins to produce enough insulin to utilize maternal glucose in the tenth week of gestation. Increases in estrogen and progesterone levels stimulate the pancreas to produce insulin. An increase in insulin promotes increased peripheral use of glucose and decreased blood glucose. This leads to decreased fasting blood glucose levels. (A)

Which major neonatal complication is carefully monitored after the birth of the infant of a diabetic mother? A. Hypoglycemia B. Hypercalcemia C. Hypobilirubinemia D. Hypoinsulinemia

The neonate is at highest risk for hypoglycemia because fetal insulin production is accelerated during pregnancy to metabolize excessive glucose from the mother. At birth, the maternal glucose supply stops and the neonatal insulin exceeds the available glucose, thus leading to hypoglycemia. Hypocalcemia is associated with preterm birth, birth trauma, and asphyxia, all common problems of the infant of a diabetic mother. Excess erythrocytes are broken down after birth and release large amounts of bilirubin into the neonate's circulation, with resulting hyperbilirubinemia. Because fetal insulin production is accelerated during pregnancy, the neonate presents with hyperinsulinemia. (A)

The nurse is caring for a pregnant client prescribed levothyroxine for hypothyroidism. The client is also prescribed an iron supplement. What information does the nurse provide the client about taking these medications? A. Take both medications together in the morning. B. Take levothyroxine 1 hour after taking the iron supplement. C. Take the iron supplement 2 hours after taking levothyroxine. D. Take the two medications at different times of the day

The nurse should teach the client to take the medications at different times of the day. Ferrous sulfate in the iron supplement decreases the absorption of T4, so their administration should be spaced at least 4 hours apart. If the medications are taken together, the levothyroxine will not be effective. The client should maintain a gap of at least 4 hours between both medications so that both medications are effective. (D)

The nurse is assessing a client for gestational diabetes mellitus (GDM) using the oral glucose tolerance test (OGTT). What intervention by the nurse is appropriate while caring for this client? A. Teach the client to eat an unrestricted diet the day before the test. B. Instruct the client to avoid caffeine for 6 hours before the test. C. Draw blood for a fasting blood glucose level just before the test. D. Obtain the plasma glucose level an hour after a 50 g oral glucose load.

The nurse must draw blood for a fasting blood glucose level just before the test begins. This is the first sample, after which blood is drawn 1, 2, and 3 hours after providing the glucose load. The nurse must teach the client to eat an unrestricted diet that includes at least 150 g of carbohydrates for at least 3 days before the test. The client must be instructed to avoid caffeine for 12 hours before the test because it increases glucose levels. The client is given a 100 g oral glucose load, and then the client's blood glucose levels are determined every hour for up to 3 hours. The plasma glucose level is obtained after a 50 g oral glucose load in the first step of screening for GDM. (C)

A 26-year-old primigravida has come to the clinic for her regular prenatal visit at 12 weeks. She appears thin and somewhat nervous. She reports that she eats a well-balanced diet, although her weight is 5 pounds less than it was at her last visit. The results of laboratory studies confirm that she has a hyperthyroid condition. Based on the available data, the nurse formulates a plan of care. What nursing diagnosis is most appropriate for the woman at this time? A. Deficient fluid volume B. Imbalanced nutrition: less than body requirements C. Imbalanced nutrition: more than body requirements D. Disturbed sleep pattern

This client's clinical cues include weight loss, which would support the nursing diagnosis of Imbalanced nutrition: less than body requirements. No clinical signs or symptoms support the nursing diagnosis of Deficient fluid volume. This client reports weight loss, not weight gain. Imbalanced nutrition: more than body requirements is not an appropriate nursing diagnosis. Although the client reports nervousness, based on the client's other clinical symptoms the most appropriate nursing diagnosis would be Imbalanced nutrition: less than body requirements. (B)

In terms of the incidence and classification of diabetes, maternity nurses should know that: A. Type 1 diabetes is most common. B. Type 2 diabetes often goes undiagnosed. C. Gestational diabetes mellitus (GDM) means that the woman will be receiving insulin treatment until 6 weeks after birth. D. Type 1 diabetes may become type 2 during pregnancy.

Type 2 diabetes often goes undiagnosed because hyperglycemia develops gradually and often is not severe. Type 2 diabetes, sometimes called adult onset diabetes, is the most common. GDM refers to any degree of glucose intolerance first recognized during pregnancy. Insulin may or may not be needed. People do not go back and forth between types 1 and 2 diabetes. (B)

***###When a pregnant woman with diabetes experiences hypoglycemia while hospitalized, what should the nurse have the woman do? Eat a candy bar. Eat 5 or 6 hard candies or drink 8 oz of milk. Drink 4 oz of orange juice followed by 8 oz of milk. Drink 8 oz of orange juice with 2 teaspoons of sugar added

Crackers provide carbohydrates in the form of polysaccharides. A candy bar provides only monosaccharides. Milk is a disaccharide and orange juice is a monosaccharide. This will provide an increase in blood sugar but will not sustain the level. Orange juice and sugar will increase the blood sugar, but not provide a slow-burning carbohydrate to sustain the blood sugar. (B)

An 18-year-old client who has reached 16 weeks of gestation was recently diagnosed with pregestational diabetes. She attends her centering appointment accompanied by one of her girlfriends. This young woman appears more concerned about how her pregnancy will affect her social life than about her recent diagnosis of diabetes. Several nursing diagnoses are applicable to assist in planning adequate care. The most appropriate diagnosis at this time is: A. Risk for injury to the fetus related to birth trauma. B. Noncompliance related to lack of understanding of diabetes and pregnancy and requirements of the treatment plan. C. Deficient knowledge related to insulin administration. D. Risk for injury to the mother related to hypoglycemia or hyperglycemia.

Before a treatment plan is developed or goals for the outcome of care are outlined, this client must come to an understanding of diabetes and the potential effects on her pregnancy. She appears to have greater concern for changes to her social life than adoption of a new self-care regimen. Risk for injury to the fetus related to either placental insufficiency or birth trauma may come much later in the pregnancy. At this time the client is having difficulty acknowledging the adjustments that she needs to make to her lifestyle to care for herself during pregnancy. The client may not yet be on insulin. Insulin requirements increase with gestation. The importance of glycemic control must be part of health teaching for this client. However, she has not yet acknowledged that changes to her lifestyle need to be made, and she may not participate in the plan of care until understanding takes place. (B)

A pregnant woman has maternal phenylketonuria (PKU) and is interested in whether or not she will be able to breastfeed her baby. Which statement made by the nurse indicates accurate information? A. The client can breastfeed the baby as long as she continues to maintain a PKU-restricted diet. B. The client should alternate breastfeedings with bottle feedings in order to reduce PKU levels provided to the baby. C. The client should be advised to not breastfeed the infant, because her breast milk will contain large amounts of phenylalanine D. The client can breastfeed for the first three months without any untoward effects on the infant.

Breastfeeding is not advised for a client who has maternal PKU, because phenylalanine levels will be high in the client's breast milk. Dietary restriction will not limit the amount of this substance in breast milk. Alternating feeding sources is not advised. (C)

The blood glucose level of a pregnant client is 325 mg/dl. Which test should be performed on the patient to assess the risk of maternal or intrauterine fetal death? A. Ketones in urine B. Glucose in urine C. Arterial blood gases D. Abdominal ultrasound

Diabetic ketoacidosis is a potentially fatal complication of diabetes that can lead to fetal death. This complication may occur if the client's blood glucose levels rise above 200mg/dl. Diabetic ketoacidosis can be confirmed by assessing the presence of ketones in the urine. The client's blood glucose level is 325 mg/dl and, hence, the patient has poorly controlled diabetes. Therefore, the nurse need not assess the urine glucose levels. Arterial blood gases and abdominal ultrasound are not useful for diagnosis of intrauterine fetal death. (A)

A pregnant woman at 14 weeks of gestation is admitted to the hospital with a diagnosis of hyperemesis gravidarum. What is the primary goal of her treatment at this time? A. Rest the gastrointestinal (GI) tract by restricting all oral intake for 48 hours. B. Reduce emotional distress by encouraging the woman to discuss her feelings. C. Reverse fluid, electrolyte, and acid-base imbalances. D. Restore the woman's ability to take and retain oral fluid and foods.

Fluid, electrolyte, and acid-base imbalances present the greatest immediate danger to the well-being of the mother and fetus and should be corrected as soon as possible. Resting the GI tract and discussing her feelings are components of treatment but are not immediate goals for this client. The ability to retain oral fluid and foods is a longer-term goal of treatment for this condition. (C)

What is gestational diabetes? A. Diabetes that accompanies hypertension B. Diabetes that begins abruptly at a young age C. Diabetes caused by absolute insulin deficiency D. Diabetes that is diagnosed during pregnancy

Gestational diabetes is a type of diabetes that did not exist before it was diagnosed during pregnancy. Hypertension is a risk factor for type 2 diabetes. Type 1 diabetes usually begins abruptly at a young age. People with type 1 diabetes have absolute insulin deficiency resulting from the destruction of beta cells in the pancreas. (D)

Which of the following findings is not likely to be seen in a pregnant client who has hypothyroidism? A. Miscarriage B. Macrosomia C. Gestational hypertension D. Placental abruption

Infants born to mothers with hypothyroidism are more likely to be of low birth weight or preterm; these outcomes can be improved with early diagnosis and treatment. Hypothyroidism is often associated with both infertility and an increased risk of miscarriage. Pregnant women with hypothyroidism are more likely to experience both preeclampsia and gestational hypertension. Placental abruption and stillbirth are risks associated with hypothyroidism. (B)

Which assessment finding does the nurse recognize as an indicator for early screening for gestational diabetes mellitus (GDM)? A. The client is 24 years old. B. The client's body mass index (BMI) is 22. C. The client does not have diabetes. D. The client had a previous stillbirth.

Screening for GDM usually takes place between 24 and 28 weeks of gestation. However, the client is screened for GDM earlier if there is a history of stillbirth or birth of a malformed or macrosomic infant. A 24-year-old client would not be considered for earlier screening for GDM; maternal age older than 25 years is a risk factor for GDM. A client with a BMI of 22 is not obese and is not considered for earlier screening for GDM. If the client does not have diabetes before gestation, the client need not be screened early for GDM. (D)

In planning for the care of a 30-year-old woman with pregestational diabetes, the nurse recognizes that which is the most important factor affecting pregnancy outcome? A. Mother's age. B. Number of years since diabetes was diagnosed. C. Amount of insulin required prenatally. D. Degree of glycemic control during pregnancy.

Women with excellent glucose control and no blood vessel disease should have good pregnancy outcomes. Although advanced maternal age may pose some health risks, the most important factor for the woman with pregestational diabetes remains the degree of glycemic control during pregnancy. The number of years since diagnosis and the amount of insulin required are not as relevant to outcomes as the degree of glycemic control. (D)

The nurse is caring for a client in the first trimester of pregnancy who is prescribed propylthiouracil (PTU) for hyperthyroidism. What are the side effects of this medication? A. Facial anomalies B. Hepatic toxicity C. Esophageal atresia D. Developmental delay

Although PTU controls the symptoms of hyperthyroidism effectively, it can cause hepatic toxicity serious enough to require liver transplantation. PTU is generally used only in the first trimester of pregnancy, after which the client is prescribed methimazole (MM). If MM is taken in the first trimester of pregnancy, it can cause facial anomalies, esophageal atresia, and developmental delay in the fetus. (B)

The nurse is assessing a client at 30 weeks of pregnancy with poorly controlled pregestational diabetes. The client has come for the antenatal visit on a Monday. When should the nurse ask the client to come next? A. Next week on a Monday B. Next week on a Thursday C. Same week on a Thursday D. Week after next week on a Monday

An antepartum client with pregestational diabetes requires more frequent antenatal visits. A client with poorly controlled diabetes who is in the third trimester of pregnancy should visit the clinic twice a week. If the client visited the clinic on a Monday, the nurse should instruct the client to come for the next visit on the same week on a Thursday. A client who is in the first and second trimester of pregnancy can come once in a week or two weeks. Because this client is in the third trimester and has poorly controlled diabetes, the nurse should not ask the client to come on next week on Monday, Thursday, or the week after next on Monday. (C)

During her pregnancy a women with pre gestational diabetes has been monitoring her blood glucose level several times a day. Which level requires further assessment?- a) 85 mg/dl - 15 min prior to breakfast b) 90 mg/dl - prior to lunch C) 140 mg/dl - 2 hours after lunch d) 126 mg/dl - 1 hour after supper

C

Maternal phenylketonuria (PKU) is an important health concern during pregnancy because: A. It is a recognized cause of preterm labor. B. The fetus may develop neurologic problems. C. A pregnant woman is more likely to die without dietary control. D. Women with PKU are usually retarded and should not reproduce.

Children born to women with untreated PKU are more likely to be born with mental retardation, microcephaly, congenital heart disease, and low birth weight. Maternal PKU has no effect on labor. Women without dietary control of PKU are more likely to miscarry or bear a child with congenital anomalies. Screening for undiagnosed maternal PKU at the first prenatal visit may be warranted, especially in individuals with a family history of the disorder, with low intelligence of uncertain etiology, or who have given birth to microcephalic infants. (B)

Diabetes in pregnancy puts the fetus at risk in several ways. Of what should the nurse be aware regarding this? A. With good control of maternal glucose levels, sudden and unexplained stillbirth is no longer a major concern. B. The most important cause of perinatal loss in diabetic pregnancy is congenital malformations. C. Infants of mothers with diabetes have the same risks for respiratory distress syndrome because of the careful monitoring. D. At birth, the neonate of a diabetic mother is no longer in any greater risk.

Congenital malformations account for 30% to 50% of perinatal deaths in diabetic pregnancies. Even with good control, sudden and unexplained stillbirth remains a major concern. Infants of diabetic mothers are at increased risk for respiratory distress syndrome, and the transition to extrauterine life is often marked by hypoglycemia and other metabolic abnormalities. (B)

A pregnant woman has contacted the nurse about severe nausea and vomiting. What is the priority assessment in evaluating a pregnant woman with severe nausea and vomiting? A. Fasting blood glucose level B. Ketonuria C. Bilirubin D. White Blood cell count

Determination of ketonuria would be a critical assessment that would lead toward determination of hyperemesis. A pregnant client with severe nausea and vomiting may have hyperemesis gravidarum and, as such, requires critical monitoring to determine the nature of the problem. A FBS, although informative would not be the priority assessment at this time. Although a bilirubin level would be needed, it would not be the priority assessment. A WBC count would indicate the possibility of an infectious source but it would not be a priority assessment in terms of the client's presentation. (B)

The priority assessment in evaluating a pregnant woman with severe nausea and vomiting is: A. Fasting blood glucose level. B. Ketonuria. C. Bilirubin. D. White blood cell count.

Determination of ketonuria would be a critical assessment that would lead towards determination of hyperemesis. A pregnant patient with severe nausea and vomiting may have hyperemesis gravidarum and as such requires critical monitoring to determine the nature of the problem. An FBS measurement, although informative, would not be the priority assessment at this time, nor would a bilirubin measurement. A WBC count would indicate the possibility of an infectious source but it would not be a priority assessment in terms of the patient's presentation. (B)

What is the pathologic change associated with diabetic ketoacidosis? A. Loss of electrolytes B. Metabolic alkalosis C. Cellular dehydration D. Increase in the blood volume

Diabetic ketoacidosis is characterized by an increase in blood sugar and ketone levels. This causes osmotic diuresis, which ultimately results in cellular dehydration. There is loss of electrolytes in ketoacidosis. Ketone bodies in the blood would result in decreased blood pH, which is referred to as metabolic acidosis. In this condition, the kidneys excrete large amounts of fluid, which results in a decrease in blood volume.

The nurse is caring for a client in early pregnancy with hyperemesis. What changes in diet will benefit this client? A. Avoiding dairy products and cold foods B. Eating a high-protein snack at bedtime C. Eating foods that are served warm D. Avoiding dry, bland, and low-fat foods

Eating a high-protein snack at bedtime may help the client overcome protein deficiency and reduce hyperemesis. The client can have dairy products, which are easily accepted by the body. Dairy products also contain proteins. Clients with hyperemesis are able to tolerate cold foods better than foods that are served warm. The client can have dry, bland, and low-fat foods, because they do not induce hyperemesis. (B)

Which patients with diabetes may develop complications if they perform exercises? Select all that apply. A. A client who is on insulin B. A client with diabetic ketoacidosis C. A client with uncontrolled hypertension D. A client with severe peripheral neuropathy E. A client who has lost 5 kg weight after diagnosis

Exercise is usually prescribed for the prevention of complications in diabetic clients. However, a client with ketoacidosis should not do exercises, because exercises burn more fats and proteins, thereby increasing the blood ketone levels. Blood pressure increases with exercise; therefore, a client with uncontrolled blood pressure should not perform exercises. A client with severe peripheral neuropathy is susceptible to injury because of loss of sensations. Therefore, exercise is contraindicated in this client. A client with insulin dependent diabetes mellitus can perform exercises under supervision. Weight loss is a common complication associated with diabetes. A client who has lost weight can perform exercises to prevent complications of diabetes. (B,C,D)

Which client may need a cesarean delivery because of complications related to gestational diabetes? A. A client with a big fetus B. A client with uterine growth C. A client with reduced fetal movement D. A client with less than normal pelvic brim

Fetal macrosomia is a common complication associated with gestational diabetes. Hypersecretion of fetal insulin hormone as a response to maternal hyperglycemia results in an increased size of the fetus. Maternal hyperglycemia does not cause the development of uterine growths. Fetal movements may be cause for a cesarean, but they are not associated with the client's gestational diabetes. The size of the pelvic brim is not altered by maternal hyperglycemia. (A)

To manage her diabetes appropriately and ensure a good fetal outcome, the pregnant woman with diabetes will need to alter her diet by: A. Eating six small equal meals per day. B. Reducing carbohydrates in her diet. C. Eating her meals and snacks on a fixed schedule. D. Increasing her consumption of protein.

Having a fixed meal schedule will provide the woman and the fetus with a steadier blood sugar level, provide better balance with insulin administration, and help prevent complications. It is more important to have a fixed meal schedule than equal division of food intake. Approximately 45% of the food eaten should be in the form of carbohydrates. (C)

A pregnant woman with type 1 diabetes is on rapid-acting, short-acting, and intermediate-acting insulin injections. Which are rapid and short-acting insulins? Select all that apply. A. NPH (Novolin N) B. Regular (Humalin) C. Lispro (Humalog) D. Aspart (NovoLog) E. Glargine (Lantus)

Humalog and NovoLog are rapid-acting insulins and Humalin is a short-acting insulin. Novolin N is an intermediate-acting insulin and Lantus is a long-acting insulin. (B, C, D)

What are the manifestations associated with hypoglycemia? Select all that apply. A. Dizziness B. Fruity breath C. Blurred vision D. Excessive hunger E. Presence of acetone in urine

Hypoglycemia refers to decreased blood sugar levels. Decreased availability of glucose impairs brain function, which results in dizziness and blurred vision. Decreased glucose levels stimulate the satiety center of the brain, which results in excessive hunger. Fruity breath and the presence of acetone in urine result from increased ketone levels in the blood. This complication may occur when the blood glucose increases over 300 mg/dl in the non-pregnant client and 200 mg/dl in the pregnant client. (A,C,D)

###Hypothyroidism occurs in 2 to 3 pregnancies per 1000. Pregnant women with untreated hypothyroidism are at risk for what? Select all that apply. A. Miscarriage B. Macrosomia C. Gestational hypertension D. Placental abruption E. Stillbirth

Hypothyroidism is often associated with both infertility and an increased risk for miscarriage. These outcomes can be improved with early diagnosis and treatment. Pregnant women with hypothyroidism are more likely to experience both preeclampsia and gestational hypertension. Placental abruption and stillbirth are risks associated with hypothyroidism. Placental abruption and stillbirth are risks associated with hypothyroidism. Infants born to mothers with hypothyroidism are more likely to be of low birth weight or preterm. (A, C, D, E)

*Hypothyroidism occurs in 2 to 3 pregnancies per 1000. Pregnant women with untreated hypothyroidism are at risk for all except: A. Miscarriage B. Macrosomia C. Gestational hypertension D. Placental abruption E. Stillbirth

Hypothyroidism is often associated with both infertility and an increased risk of miscarriage. Infants born to mothers with hypothyroidism are more likely to be of low birth weight or preterm. These outcomes can be improved with early diagnosis and treatment. Pregnant women with hypothyroidism are more likely to experience both preeclampsia and gestational hypertension. Placental abruption and stillbirth are risks associated with hypothyroidism. Placental abruption and stillbirth are risks associated with hypothyroidism. (B)

###What are the metabolic changes associated with pregnancy? Select all that apply. Maternal production of insulin increases during the first trimester. Fasting blood glucose levels will decrease during the first trimester. The patient's tolerance to glucose increases in the second trimester. There is enough glucose for the fetus during the second trimester. Maternal insulin requirements increase during the first trimester.

In the first trimester, an increase in estrogen and progesterone production stimulates the beta cells in the pancreas to increase insulin production. The beta cells also increase peripheral use of glucose and, in turn, decrease the overall blood glucose levels. This reduces fasting glucose levels by approximately 10%. During the second and third trimesters hormonal changes increase insulin resistance and ensure an abundant supply of glucose for the fetus. The body develops insulin resistance as a glucose-sparing mechanism. In the second trimester hormonal changes decrease tolerance to glucose. Maternal insulin requirements increase from 18 to 24 weeks of gestation, not in the first trimester. (A,B,D)

In assessing the knowledge of a pregestational woman with type 1 diabetes concerning changing insulin needs during pregnancy, the nurse recognizes that further teaching is warranted when the client states: a. "I will need to increase my insulin dosage during the first 3 months of pregnancy." b. "Insulin dosage will likely need to be increased during the second and third trimesters." c. "Episodes of hypoglycemia are more likely to occur during the first 3 months." d. "Insulin needs should return to normal within 7 to 10 days after birth if I am bottle-feeding."

Insulin needs are reduced in the first trimester because of increased insulin production by the pancreas and increased peripheral sensitivity to insulin. "Insulin dosage will likely need to be increased during the second and third trimesters," "Episodes of hypoglycemia are more likely to occur during the first 3 months," and "Insulin needs should return to normal within 7 to 10 days after birth if I am bottle-feeding" are accurate statements and signify that the woman has understood the teachings regarding control of her diabetes during pregnancy. (A)

Nursing intervention for the pregnant diabetic patient is based on the knowledge that the need for insulin: A. Increases throughout pregnancy and the postpartum period. B. Decreases throughout pregnancy and the postpartum period. C. Varies depending on the stage of gestation. D. Should not change because the fetus produces its own insulin.

Insulin needs decrease during the first trimester, when nausea, vomiting, and anorexia are a factor. They increase during the second and third trimesters, when the hormones of pregnancy create insulin resistance in maternal cells. Insulin needs increase during the second and third trimesters, when the hormones of pregnancy create insulin resistance in maternal cells. The insulin needs change throughout the different stages of pregnancy. (C)

***The nurse is teaching a woman with gestational diabetes the technique to inject insulin. What should the nurse include in the teaching session? Select all that apply. A. Aspirate before injecting. B. Clean injection site with alcohol. C. Insert the needle at a 90-degree angle. D. Inject insulin slowly. E. After injection, cover site with sterile gauze.

Insulin should be injected with the short needle inserted at a 45- to 90-degree angle, depending on fatty tissue. Insulin is injected slowly to allow tissue expansion and minimize pressure, which can cause insulin leakage. After injection, the site should be covered with sterile gauze. Gentle pressure should be applied to prevent bleeding. Aspirating when injecting into subcutaneous tissue is not necessary. The injection site should be clean, but using alcohol is not necessary. (C,D,E)

The nurse is advising a pregnant client who has been prescribed lispro (Humalog). What information does the nurse provide about the insulin? Select all that apply. A. It is rapid-acting insulin preferred for use during pregnancy. B. It is injected just before meals and causes less hyperglycemia. C. It has shorter duration of action as compared to regular insulin. D. It is released slowly in small amounts with no pronounced peak. E. Its action lasts for 12 hours maintaining optimal blood glucose levels.

Lispro (Humalog) is rapid-acting insulin preferred for use during pregnancy. It is convenient, because it is injected just before mealtime. It causes less hyperglycemia and fewer hypoglycemic episodes. It has a shorter duration of action as compared to regular insulin. Lispro (Humalog) is not released slowly in small amounts. Glargine (Lantus) is long-acting insulin that is released slowly in small amounts with no pronounced peak. The action of lispro (Humalog) lasts for 3 to 5 hours. Therefore clients often need additional longer-acting insulin to maintain optimal blood glucose levels. (A,B,C)

***The nurse is assessing a pregnant client at 16 weeks of gestation. Which diagnostic test should the nurse say is used to identify neural tube defects in the fetus? A. Serum alpha-fetoprotein B. Fetal echocardiography C. Glycosylated hemoglobin D. Nonstress test (NST)

Measurement of maternal serum alpha-fetoprotein is performed between 16 and 18 weeks of gestation to determine the risk of neural tube defects. The fetus is at increased risk for neural tube defects such as spina bifida, anencephaly, and microcephaly. Fetal echocardiography is performed between 20 and 22 weeks of gestation to detect cardiac anomalies. Glycosylated hemoglobin is measured to assess glycemic control over the previous 4 to 6 weeks. The nonstress test (NST) is performed between 28 and 32 weeks of gestation in clients with vascular disease or poor glucose control. The NST is used to evaluate fetal well-being. (A)

A pregnant patient experiences thyroid storm following delivery of her infant. What interventions would the nurse anticipate to be ordered by the physician? (Select all that apply.) A. Restriction of intravenous fluids to prevent fluid overload B. Administration of oxygen C. Antipyretics D. Synthroid E. PTU

Oxygen would be provided, antipyretics would be given to reduce fever, and PTU would be administered. IV fluids would be administered to the patient in order to reverse the hypotension that the patient would be experiencing. Synthroid would not be given because it is used to treat hypothyroidism, and with thyroid storm, the patient is suffering from hyperthyroidism. (B,C,E)

*A new mother with which of these thyroid disorders would be strongly discouraged from breastfeeding? A. Hyperthyroidism B. Phenylketonuria (PKU) C. Hypothyroidism D. Thyroid storm

PKU is a cause of mental retardation in infants; mothers with PKU pass on phenylalanine. A woman with hyperthyroidism or hypothyroidism would have no particular reason not to breastfeed. A thyroid storm is a complication of hyperthyroidism. (B)

What are maternal and neonatal risks associated with gestational diabetes mellitus? A. maternal premature rupture of membranes and neonatal sepsis. B. maternal hyperemesis and neonatal low birth weight. C. maternal preeclampsia and fetal Macrosomia. D. maternal placenta previa and fetal prematurity.

Premature rupture of membranes and neonatal sepsis are not risks associated with gestational diabetes. Hyperemesis is not seen with gestational diabetes, nor is there an association with low birth weight of the infant. Women with gestational diabetes have twice the risk of developing hypertensive disorders such as preeclampsia, and the baby usually has macrosomia. Placental previa and subsequent prematurity of the neonate are not risks associated with gestational diabetes. (C)

Glucose metabolism is profoundly affected during pregnancy because: a. Pancreatic function in the islets of Langerhans is affected by pregnancy. b. The pregnant woman uses glucose at a more rapid rate than the nonpregnant woman. c. The pregnant woman increases her dietary intake significantly. d. Placental hormones are antagonistic to insulin, thus resulting in insulin resistance.

Placental hormones, estrogen, progesterone, and human placental lactogen (HPL) create insulin resistance. Insulin also is broken down more quickly by the enzyme placental insulinase. Pancreatic functioning is not affected by pregnancy. The glucose requirements differ because of the growing fetus. The pregnant woman should increase her intake by 200 calories a day. (D)

What are the complications associated with polyhydramnios? Select all that apply. A. Ketoacidosis B. Placental abruption C. Uterine dysfunction D. Gestational diabetes E. Postpartum hemorrhage

Polyhydramnios is a condition in which the amniotic fluid index becomes greater than 25 cm. An increase in the amniotic fluid may lead to placental abruption, which needs immediate intervention. This condition also impairs the uterine function. Polyhydramnios also results in excessive blood loss after delivery, which is referred to as postpartum hemorrhage. Ketoacidosis may occur when the blood sugar levels go beyond 200 mg/dl. Gestational diabetes can cause polyhydramnios. However, it is not a complication of polyhydramnios. (B, C, E)

###The nurse is caring for a client with poorly controlled gestational diabetes. What risks to the fetus does the nurse anticipate during the later pregnancy stages and birthing process? Select all that apply. A. Ketoacidosis B. Macrosomia C. Shoulder dystocia D. Facial nerve injury E. Hyperglycemia

Poor glycemic control during the later stages of pregnancy increases the rate of fetal macrosomia, defined as a birth weight of more than 4000 g. The macrosomic fetus of the diabetic mother tends to have a disproportionate increase in shoulder, trunk, and chest size, leading to risk of shoulder dystocia. Failure of fetal descent or labor progress leads to difficult vaginal birth. A vaginal birth may lead to birth injuries in the infant, such as facial nerve injury. Ketoacidosis is a result of uncontrolled glycemia, which affects the mother during pregnancy. Hypoglycemia, not hyperglycemia, is a risk for infants born to diabetic mothers. In the later stages of pregnancy, hypoglycemia may occur as insulin doses are adjusted to maintain a normal blood glucose level. (B,C,D)

Screening at 24 weeks of gestation reveals that a pregnant woman has gestational diabetes mellitus (GDM). In planning her care, the nurse and the woman mutually agree that an expected outcome is to prevent injury to the fetus as a result of GDM. The nurse identifies that the fetus is at greatest risk for: A. Macrosomia. B. Congenital anomalies of the central nervous system. C. Preterm birth. D.Low birth weight.

Poor glycemic control later in pregnancy increases the rate of fetal macrosomia. Poor glycemic control during the preconception time frame and into the early weeks of the pregnancy is associated with congenital anomalies. Preterm labor or birth is more likely to occur with severe diabetes and is the greatest risk in women with pregestational diabetes. Increased weight, or macrosomia, is the greatest risk factor for this woman. (A)

###For what condition is a client at risk in early pregnancy due to poorly controlled hyperglycemia? A. Miscarriage B. Hydramnios C. Preeclampsia D. Ketoacidosis

Poorly controlled hyperglycemia at the time of conception and early pregnancy often leads to miscarriage. The risk of having a miscarriage increases with the duration and severity of the client's diabetes. Hydramnios occurs in the third trimester of pregnancy in the diabetic client. It may be due to increased glucose concentration in the amniotic fluid from maternal and fetal hyperglycemia, which induces fetal polyuria. Preeclampsia occurs in later pregnancy and in the postpartum period. Pregnant clients with poorly controlled hyperglycemia at the beginning of pregnancy, especially if combined with nephropathy and hypertension, are at higher risk of developing preeclampsia. Ketoacidosis occurs in the second and third trimesters. This is the accumulation of ketones in the body due to hyperglycemia, and it may lead to metabolic acidosis. (A)

Preconception counseling is critical to the outcome of diabetic pregnancies because poor glycemic control before and during early pregnancy is associated with: a. Frequent episodes of maternal hypoglycemia. b. Congenital anomalies in the fetus. c. Polyhydramnios. d. Hyperemesis gravidarum.

Preconception counseling is particularly important because strict metabolic control before conception and in the early weeks of gestation is instrumental in decreasing the risks of congenital anomalies. Frequent episodes of maternal hypoglycemia may occur during the first trimester (not before conception) as a result of hormone changes and the effects on insulin production and usage. Hydramnios occurs about 10 times more often in diabetic pregnancies than in nondiabetic pregnancies. Typically it is seen in the third trimester of pregnancy. Hyperemesis gravidarum may exacerbate hypoglycemic events because the decreased food intake by the mother and glucose transfer to the fetus contribute to hypoglycemia. (B)

A client who is pregnant already has type 2 diabetes and a hemoglobin A1c of 7. What does the nurse would categorize this client as having? A. Gestational diabetes. B. Insulin-dependent diabetes complicated by pregnancy. C. Pregestational diabetes mellitus. D. Non-insulin-dependent diabetes with complications.

Pregestational diabetes mellitus is a term used to describe type 1 or type 2 diabetic clients in whom the diabetes existed prior to pregnancy. Gestational diabetes occurs when during the pregnancy, a woman becomes diabetic. A type 2 diabetic is non-insulin dependent. This option indicates type 1, or insulin-dependent, diabetes. There is no information presented that indicates complications at this point, because the hemoglobin A1c is within normal range, indicating adequate glycemic control. (C)

The insulin dose of a client in the second trimester of pregnancy has been increased. When does the nurse expect the client's prepregnant dose of insulin to be recommended again? A. When the client starts lactating B. When the client delivers the baby C. When the client is in the third trimester D. When the client weans the baby from breastfeeding

Pregnancy hormones cause increased glucose tolerance and decreased sensitivity to insulin. This results in an increased need of insulin to obtain glycemic control. In this case, the client's glucose metabolism would reach its prepregnant state only when the client stops breastfeeding the baby. During lactation, the maternal glucose is utilized and, therefore, the client would require a low dose of insulin. When the client delivers the baby, the insulin-glucose levels do not return to their nonpregnant state immediately. Therefore, the client still has to continue with the recommended high insulin dose for some time. During the third trimester, the diabetogenic effect of hormones is excessive, and maternal insulin requirements may double. (D)

Metabolic changes throughout pregnancy that affect glucose and insulin in the mother and the fetus are complicated but important to understand. Nurses should understand that: A. Insulin crosses the placenta to the fetus only in the first trimester, after which the fetus secretes its own. B. Women with insulin-dependent diabetes are prone to hyperglycemia during the first trimester because they are consuming more sugar. C. During the second and third trimesters, pregnancy exerts a diabetogenic effect that ensures an abundant supply of glucose for the fetus. D. Maternal insulin requirements steadily decline during pregnancy.

Pregnant women develop increased insulin resistance during the second and third trimesters. Insulin never crosses the placenta; the fetus starts making its own insulin around the tenth week. As a result of normal metabolic changes during pregnancy, insulin-dependent women are prone to hypoglycemia (low levels). Maternal insulin requirements may double or quadruple by the end of pregnancy. (C)

Which factor is known to increase the risk of gestational diabetes mellitus? A. Underweight before pregnancy B. Maternal age younger than 25 years C. Previous birth of large infant D. Previous diagnosis of type 2 diabetes mellitus

Previous birth of a large infant suggests gestational diabetes mellitus. Obesity (BMI of 30 or greater) creates a higher risk for gestational diabetes. A woman younger than 25 years generally is not at risk for gestational diabetes mellitus. The person with type 2 diabetes mellitus already has diabetes and will continue to have it after pregnancy. Insulin may be required during pregnancy because oral hypoglycemia drugs are contraindicated during pregnancy. (C)

With regard to the association of maternal diabetes and other risk situations affecting mother and fetus, nurses should be aware that: A. Diabetic ketoacidosis (DKA) can lead to fetal death at any time during pregnancy. B. Hydramnios occurs approximately twice as often in diabetic pregnancies. C. Infections occur about as often and are considered about as serious in diabetic and nondiabetic pregnancies. D. Even mild to moderate hypoglycemic episodes can have significant effects on fetal well-being.

Prompt treatment of DKA is necessary to save the fetus and the mother. Hydramnios occurs 10 times more often in diabetic pregnancies. Infections are more common and more serious in pregnant women with diabetes. Mild to moderate hypoglycemic episodes do not appear to have significant effects on fetal well-being. (A)

Which questions does the nurse ask to determine whether a 28-year-old client is at significant risk for pulmonary embolism? A. "Have you experienced any menstrual disturbances recently?" B. "Are you undergoing hormone replacement therapy?" C. "Do any of your family members have a history of factor V Leiden?" D. "Do any of your family members have a history of neurofibromatosis?"

Pulmonary embolism is most prevalent in clients with factor V Leiden (FVL). Because FVL is an autosomal dominant disorder, the nurse asks the client whether any family members have FVL. Menstrual disturbance and the presence of clots in the lungs are not associated with a mutation in the factor V gene. Hormonal replacement therapy would be prescribed for clients going through menopause, not clients with a pulmonary embolism. Neurofibromatosis is a disorder associated with the formation of tumors; it is not associated with pulmonary embolism. (C)

A pregnant woman at 28 weeks of gestation has been diagnosed with gestational diabetes. The nurse caring for this client understands that: A. Oral hypoglycemic agents can be used if the woman is reluctant to give herself insulin. B. Dietary modifications and insulin are both required for adequate treatment. C. Glucose levels are monitored by testing urine four times a day and at bedtime D. Dietary management involves distributing nutrient requirements over three meals and two or three snacks.

Small frequent meals over a 24-hour period help decrease the risk for hypoglycemia and ketoacidosis. Oral hypoglycemic agents can be harmful to the fetus and less effective than insulin in achieving tight glucose control. In some women gestational diabetes can be controlled with dietary modifications alone. Blood, not urine, glucose levels are monitored several times a day. Urine is tested for ketone content; results should be negative. (D)

The nurse is caring for a client with insulin-dependent diabetes mellitus in the first trimester of pregnancy. The client feels dizzy and lethargic and her blood glucose level is 50 mg/dl. What should the nurse do first in this situation? A. Ask the dietician to recommend a sugar free diet to the client. B. Assess the client for symptoms of retinopathy and nephropathy. C. Assess the serum progesterone and estrogen levels in the client. D. Provide the client a dose of glucose gel or a few glucose tablets.

Symptoms such as dizziness and lethargy, as well as a blood glucose level of 50mg/dl, indicate that the client may have hypoglycemia or be in insulin shock. Pregnant client with insulin-dependent diabetes mellitus are extremely prone to hypoglycemia during the first trimester, because estrogen and progesterone stimulate the release of insulin. In this situation, the nurse should give the client fast glucose in the form of a gel or tablets to quickly stabilize the client . If the client is hypoglycemic, the nurse should not ask the dietician to prescribe a completely sugar-free diet. The signs and symptoms of the client do not indicate that the client may have retinopathy and nephropathy. The progesterone and estrogen levels are high in a pregnant client In this situation, it is not important to assess the levels of these hormones. (D)

For which condition should the nurse be alert after administering terbutaline (Brethine) to a pregnant client with diabetes mellitus? A. Dyspnea B. Infection C. Ketoacidosis D. Hypoglycemia

Terbutaline (Brethine) is a beta-mimetic drug administered for tocolysis to stop preterm labor. It may lead to hyperglycemia and cause ketoacidosis in the pregnant client. Dyspnea on exertion may be seen in a pregnant patient with acquired cardiac disease. Infection in pregnant women happens due to an alteration in the normal resistance of the body to infection. Hypoglycemia occurs if there is an increase in the insulin levels. (C)

The nurse is using White's classification of diabetes in pregnancy. What are the features of White's classification? Select all that apply. A. It considers the duration of diabetes in the client. B. It is based on the age at which diabetes was diagnosed. C. It is based on the involvement of the eye and the kidneys. D. It classified as type 1, type 2, others, and gestational diabetes. E. It considers two groups with and without vascular complications.

The White's classification system considers the duration of diabetes in the client. It is based on the age at which the illness was diagnosed. It also considers the involvement of the end-organs, which are the eye and the kidneys. The American Diabetes Association (ADA) classifies diabetes into four mutually exclusive categories. They are type 1, type 2, others, and gestational diabetes. In this classification method, type 1 and type 2 diabetes are further classified into two groups. One group includes those with vascular complications and the other group includes those without vascular complications. (A, B, C)

The nurse is caring for a diabetic client who is breastfeeding her infant. Within what time frame following childbirth do the client's insulin requirements return to prepregnancy levels? A. Immediately after childbirth B. Seven to 10 days after childbirth C. On completion of weaning D. During the lactation period

The breastfeeding mother's insulin requirements return to prepregnancy levels after the infant has been completely weaned. At birth, there is a sudden drop in the levels of insulinase following expulsion of the placenta, but they do not return to prepregnancy levels. When the mother is not breastfeeding, the insulin carbohydrate balance returns in 7 to 10 days. Maternal glucose is used up during lactation; therefore the breastfeeding mother's insulin requirement remains low. (C)

The nurse is teaching a client how to monitor blood glucose using a glucose meter. Arrange the steps of the procedure in the correct order for the client to perform. A. Record the results displayed on the meter. B. Pierce the site with a lancet. C. Select a site on the side of a finger. D. Gently squeeze the finger. E. Let blood be drawn into the test strip. F. Wash hands with warm water.

The client must wash the hands with warm water to improve circulation. A site is selected on the side of any finger. The nurse instructs the client to use all fingers in rotation. The selected site is pierced with a lancet. The other hand is used to gently squeeze a drop of blood from the pierced finger. The client must allow the drop of blood to be drawn into the test strip. The meter displays blood glucose levels, which must be recorded. (in order F,C,B,D,E,A)

After reviewing the blood glucose levels of a client, the nurse finds that the client is hypoglycemic and gives three glucose tablets to the client. After 15 minutes, the nurse finds that the client is still hypoglycemic, and again administers three glucose tablets. What should the nurse do next, if the client's blood glucose is 60 mg/dl after 15 minutes? A. Notify the primary health care provider. B. Administer 50% dextrose intravenous push. C. Obtain blood samples for blood gas analysis. D. Give three more glucose tablets to the client.

The hypoglycemic client's blood sugar level has not risen after giving three glucose tablets twice over an interval of 15 minutes each. In this situation, the nurse should notify the primary health care provider so that emergency intervention can be provided. Administering three more glucose tablets would not be of use, because this intervention had not been useful to improve the client's blood sugar level previously. An intravenous push of 50% dextrose should be done if the hypoglycemic client has become unconscious. In this case, arterial blood gas analysis would not be helpful in finding out the cause of persistent low blood sugar. (A.)

A cesarean birth is planned for a diabetic client with fetal macrosomia. Which intervention by the nurse is appropriate when preparing the client for surgery? A. Instruct the client to avoid insulin the night before the surgery. B. Administer a full dose of insulin on the morning of the surgery. C. Ensure the client has nothing by mouth on the morning of the surgery. D. Infuse intravenous 5% dextrose if the client's glucose level is below 100 mg/dl.

The nurse must ensure the client is not given anything by mouth on the morning of the surgery. The client must take a full dose of insulin at bedtime the night before surgery. The client is fasting; therefore insulin is not administered on the morning of the surgery. The client is given intravenous 5% dextrose if her glucose levels fall below 70 mg/dl during active labor. (C)

The nurse is caring for a client with gestational diabetes. What does the nurse teach the client about using insulin? A. Store unused vials of insulin in the freezer. B. Shake the prepared syringes well before use. C. Administer long-acting insulin before meals. D. Inject insulin in the abdomen.

The nurse must teach the client that the abdomen is the preferred site for injecting insulin, because insulin is best absorbed in the abdominal area. Other suitable sites include the upper outer arm, the thighs, and the buttocks. Insulin must not be frozen, so unused vials of insulin are stored in the refrigerator, but not in the freezer. Syringes containing mixed insulin may be stored for up to 2 weeks in the refrigerator. The syringe must not be shaken; it must be gently rotated 20 times before injection. Long-acting insulin is usually administered at bedtime, because it provides glucose control for a longer duration. (D)

The nurse is teaching a client insulin self-administration techniques. What does the nurse include in the lesson? Select all that apply. A. Allow the alcohol to dry before injecting the insulin. B. Puncture the skin at a 45-degree angle. C. Ensure that the insulin is injected rapidly. D. Apply gentle pressure after the injection. E. Record the dose and time of the injection.

The nurse should instruct the client to ensure that the injection site is clean. The site does not need to be cleaned with alcohol; if alcohol is applied, insulin should be injected only after the alcohol dries. Gentle pressure should be applied with sterile gauze while withdrawing the needle after injection to prevent bleeding. The client should maintain a record of the dose and time of injection. Insulin should be administered by puncturing the skin at a 90-degree angle. Insulin should be injected slowly into the skin. (A,D,E)

What does the nurse instruct a pregnant client who is diabetic to do? Select all that apply. A. "Perform exercises just before meals." B. "Perform exercises with a partner." C. "Stop exercising if contractions occur." D. "Lie supine if contractions occur." E. "Exercise at the same time every day."

The nurse should instruct the client to exercise with a partner as a safety measure. The client should be instructed to stop exercising immediately if contractions occur. The client should perform exercises, eat meals, and take insulin at the same time every day. It is best to perform exercises after meals, when the blood glucose levels are rising. If contractions occur, the client should drink two to three glasses of water and lie down on her side for an hour. If contractions do not cease, the client should contact the primary health care provider. (B,C,E)

The nurse is caring for a diabetic client who is pregnant. What does the nurse instruct the client about self-care during illness? Select all that apply. A. Avoid insulin if your appetite is less than normal. B. Drink as much fluid as possible. C. Obtain as much rest as possible. D. Check your blood glucose levels at regular intervals. E. Seek treatment if your glucose level exceeds 250 mg/dl.

The nurse should teach the client to drink as much fluid as possible to prevent dehydration. The client should get plenty of rest to speed up recovery from illness. Blood glucose levels should be monitored at regular intervals as a precautionary measure to identify hypoglycemia. The client should be taught to take insulin as per her regular schedule even if her appetite is less than normal, because insulin requirements increase during illness. The client should seek emergency treatment as soon as her glucose level exceeds 200 mg/dl. (B, C, D)

A pregestational diabetic woman at 20 weeks of gestation exhibits the following: thirst, nausea and vomiting, abdominal pain, drowsiness, and increased urination. Her skin is flushed and dry and her breathing is rapid with a fruity odor. A priority nursing action when caring for this woman would be to: A. provide the woman with a simple carbohydrate immediately. B. request an order for an antiemetic. C. assist the woman into a lateral position to res. D. administer insulin according to the woman's blood glucose level.

The woman is exhibiting signs of DKA; insulin is the required treatment, with the dosage dependent on blood glucose level; intravenous fluids may also be required; choice a is the treatment for hypoglycemia; choices b and c, although they may increase the woman's comfort, are not priorities. (D)