Ch. 20
What happens to renal and perfusion rate in preeclampsia?
-Decreased renal perfusion and glomerular filtration rate -Decreased output and retention of sodium -Increased serum levels of creatinine, BUN, uric acid
Gestational diabetes?
Usually detected around 24th week p. 734
Is edema in mild preeclampsia?
No, but generalized edema may be present
Congenital anomalies caused by hyperglycemia in 1st trimester?
Cardiac issues, neural tube defects, skeletal deformities and genitourinary problems p. 735 Table 20.2
What to look at with the CBC in preeclampsia?
Hgb and plts
Pregestational diabetes?
Identified before conception p. 734
(Preeclampsia) Protein/creatinine ratio?
Greater than or equal to 0.3
(Preeclampsia) 24hr urine collection result that is abnormal?
Greater than or equal to 300mg
Criteria that indicates no gestational diabetes may be present for prenatal visits?
-No hx of glucose intolerance -Less than 25y.o. -Normal body weight -No family hx -No poor obstetric outcome in the past -Not from ethnic group w/ GDM p. 736
Cutoff for gestational diabetes at 24-28w?
92 mg/dL fasting 180 mg/dL 75g OGTT-1hr 153 mg/dL 75g OGTT-2hr Table 20.1 p. 734
Fetus complication from preterm labor secondary to premature membrane rupture?
Birth trauma due to increased fetus size such as shoulder dystocia p. 735 Table 20.2
A nurse is caring for a pregnant client with eclamptic seizure. Which is a characteristic of eclampsia? Muscle rigidity is followed by facial twitching. Respirations are rapid during the seizure. Coma occurs after seizure. Respiration fails after the seizure.
Coma occurs after seizure. Explanation: The nurse should know that coma usually follows an eclamptic seizure. Muscle rigidity occurs after facial twitching. Respirations do not become rapid during the seizure; they cease. Coma usually follows the seizure activity, with respiration resuming. Chapter 19: Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications - Page 686
Hydramnios due to fetal diuresis caused by hyperglycemia does what to the fetus?
Cord prolapse secondary to polyhydraminos and abnormal fetal presentation p. 735 Table 20.2
Blood pressure for severe preeclampsia?
Greater or equal to 160/110 on two occasions at least 6 hrs apart during bed rest
(Preeclampsia) HELLP?
Hemolysis Elevated liver enzymes Low platelet count
(Preeclampsia) If no proteinuria what will platelets look like?
Less than 100,000
Diagnosis cutoff for pregestational diabetes at the first prenatal visit?
126mg/dL fasting <7% HbA1C 200 mg/dL random Table 20.1 p. 734
(Preeclampsia) If no proteinuria then serum creatinine conc?
>1.1mg/dl or doubling of serum concentration in absence of other renal disease
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 Daily insulin injections for gestational diabetes Monthly hemoglobin A1C levels to rule out diabetes Daily fingersticks for a fasting blood glucose level
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. Chapter 20: Nursing Management of the Pregnancy at Risk: Selected Health Conditions and Vulnerable Populations - Page 708
(Preeclampsia) If no proteinuria then what would liver enzymes look like?
Elevated AST/ALT
Preeclampsia risk factors?
Nulliparity Preeclampsia in a previous pregnancy Age >40 yrs or <18 Family hx of pregnancy induced hypertension Chronic htn Chronic renal disease Antiphospholipid antibody syndrome or inherited thrombophilia Vascular or connective tissue disease Diabetes mellitus (pregestational or gestational) Multifetal gestation High body mass index Male partner whose previous partner had preeclampsia Unexplained fetal growth restriction
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 long-acting insulin oral hypoglycemic drugs glucagon
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. Chapter 20: Nursing Management of the Pregnancy at Risk: Selected Health Conditions and Vulnerable Populations - Page 709
A woman is being closely monitored and treated for severe preeclampsia with magnesium sulfate. Which finding would alert the nurse to the development of magnesium toxicity in this client? diminished reflexes elevated liver enzymes seizures serum magnesium level of 6.5 mEq/L
diminished reflexes Explanation: Diminished or absent reflexes occur when a client develops magnesium toxicity. Elevated liver enzymes are unrelated to magnesium toxicity and may indicate the development of HELLP syndrome. The onset of seizure activity indicates eclampsia. A serum magnesium level of 6.5 mEq/L would fall within the therapeutic range of 4 to 7 mEq/L. Chapter 19: Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications - Page 688
A nurse is conducting a class on gestational diabetes for a group of pregnant women who are at risk for the condition. The nurse determines that additional teaching is needed when the class identifies which complication as affecting the neonate? hyperglycemia macrosomia hypoglycemia birth trauma
hyperglycemia Explanation: Gestational diabetes is associated with either neonatal complications such as macrosomia, hypoglycemia, and birth trauma or maternal complications such as preeclampsia and cesarean birth. Chapter 20: Nursing Management of the Pregnancy at Risk: Selected Health Conditions and Vulnerable Populations - Page 707
The following hourly assessments are obtained by the nurse on a client with preeclampsia receiving magnesium sulfate: 97.3oF (36.2oC), HR 88, RR 12 breaths/min, BP 148/110 mm Hg. What other priority physical assessments by the nurse should be implemented to assess for potential toxicity? lung sounds oxygen saturation reflexes magnesium sulfate level
reflexes Explanation: Reflex assessment is part of the standard assessment for clients on magnesium sulfate. The first change when developing magnesium toxicity may be a decrease in reflex activity. The health care provider needs to be notified immediately. A change in lung sounds and oxygen saturation are not indicative of magnesium sulfate toxicity. Hourly blood draws to gain information on the magnesium sulfate level are not indicated. Chapter 19: Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications - Page 689
(Preeclampsia) Decreased or increased viscosity of blood?
Increased
A pregnant woman with preeclampsia is to receive magnesium sulfate IV. Which assessment should the nurse prioritize before administering a new dose? blood pressure patellar reflex heart rate anxiety level
patellar reflex Explanation: A symptom of magnesium sulfate toxicity is loss of deep tendon reflexes. Assessing for the patellar reflex or ankle clonus before administration is assurance the drug administration will be safe. Assessing the blood pressure, heart rate, or anxiety level would not reveal a potential magnesium toxicity. Chapter 19: Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications - Page 689
The nurse is caring for a client with preeclampsia and understands the need to auscultate this client's lung sounds every 2 hours to detect which condition? pulmonary hypertension pulmonary edema pulmonary emboli pulmonary atelectasis
pulmonary edema Explanation: In the hospital, monitor blood pressure at least every 4 hours for mild preeclampsia and more frequently for severe disease. In addition, it is important to auscultate the lungs every 2 hours. Adventitious sounds may indicate developing pulmonary edema. Chapter 19: Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications - Page 683
A nurse is providing care to a pregnant client hospitalized with preeclampsia. The nurse immediately notifies the health care provider that the client has developed eclampsia based on which finding? blood pressure greater than 160/100 mm Hg hyperreflexia proteinuria seizure activity
seizure activity Explanation: Although a blood pressure greater than 160/110 mm Hg, hyperreflexia and proteinuria are associated with eclampsia. The onset of seizure activity identifies eclampsia. Chapter 19: Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications - Page 690
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: limit weight gain to 15 pounds during the pregnancy. check her blood sugars frequently and adjust insulin accordingly. exercise for 1 to 2 hours each day to keep the blood glucose down. begin oral hyperglycemic medications along with the insulin she is currently taking.
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. Chapter 20: Nursing Management of the Pregnancy at Risk: Selected Health Conditions and Vulnerable Populations - Page 706
The nurse is orientating in the Labor and Delivery unit and asks her preceptor how to differentiate a client with preeclampsia from one with eclampsia. Which symptoms would the preceptor describe to the new nurse as indicative of severe preeclampsia? Select all that apply. Blood pressure above 160/110 mm Hg Nondependent edema Glycosuria Seizure Hyperactive deep tendon reflexes
Blood pressure above 160/110 mm Hg Nondependent edema Hyperactive deep tendon reflexes Explanation: Preeclampsia occurs when a pregnant woman develops hypertension occurring after 20 weeks' gestation and only resolves after the fetus is delivered. Preeclampsia is exhibited by 2+ or more proteinuria, nondependent edema, blood pressure greater than 140 mm Hg systolic and above 90 mm Hg diastolic, and CNS irritability demonstrated by hyperactive deep tendon reflexes. If the client has a seizure, she has moved to eclampsia. Glycosuria is not associated with preeclampsia.
The nurse is educating a client with type 1 diabetes about the complications associated with diabetes and pregnancy. Which problems would the nurse include in her teaching? Select all that apply. Decreased birth weight Increased risk of spontaneous abortion (miscarriage) Polyhydramnios Hypertension Cystic fibrosis
Increased risk of spontaneous abortion (miscarriage) Polyhydramnios Hypertension Explanation: Women with pregestational diabetes, which is type 1 diabetes, are at a higher risk of having an infant with complications during the pregnancy and at the birth. Spontaneous abortion (miscarriage) is higher in women who have pregestational diabetes. Also, they run a higher risk of having a pregnancy with polyhydramnios, and of developing maternal hypertension. The birth weight of an infant born to a mother with diabetes is increased, not decreased. Cystic fibrosis is not associated with maternal diabetes. Chapter 20: Nursing Management of the Pregnancy at Risk: Selected Health Conditions and Vulnerable Populations - Page 712
Preeclampsia patho?
-Improper placental invasion -Reduced trophoblastic invasion resulting in improper remodeling of spiral arteriols
A woman at 26 weeks' gestation is undergoing screening for diabetes with a 1-hour oral glucose challenge test. On the client's return visit, the nurse anticipates the need to schedule a 3-hour glucose challenge test based on which result of the previous test? 100 mg/dl (5.55 mmol/L) 114 mg/dL (6.33 mmol/L) 130 mg/dL (7.21 mmol/L) 146 mg/dL (8.10 mmol/L)
146 mg/dL (8.10 mmol/L) Explanation: For a 1-hour glucose challenge test, a 75-g oral glucose load is given, without regard to the timing or content of the last meal. Blood glucose is measured 1 hour later; a level above 140 mg/dl (7.77 mmol/L)is abnormal. If the result is abnormal, a 3-hour glucose tolerance test is done. Chapter 20: Nursing Management of the Pregnancy at Risk: Selected Health Conditions and Vulnerable Populations - Page 708
The nurse is caring for a pregnant woman determined to be at high risk for gestational diabetes. The nurse prepares to rescreen this client at which time frame? 16 to 20 weeks 20 to 24 weeks 24 to 28 weeks 28 to 32 weeks
24 to 28 weeks Explanation: A woman identified as high risk for gestational diabetes would undergo rescreening between 24 and 28 weeks; however, some health care providers can choose to conduct this screening earlier. Chapter 20: Nursing Management of the Pregnancy at Risk: Selected Health Conditions and Vulnerable Populations - Page 707
A client has been admitted to the hospital with a diagnosis of preeclampsia with severe features. Which nursing intervention is the priority? Confine the client to bed rest in a darkened room. Administer oxygen by face mask. Keep the client on her side so that secretions can drain from her mouth. Check for vaginal bleeding every 15 minutes.
Confine the client to bed rest in a darkened room. Explanation: With preeclampsia with severe features, most women are hospitalized so that bed rest can be enforced and a woman can be observed more closely than she can be on home care. The nurse should darken the room if possible because a bright light can also trigger seizures. The other interventions listed pertain to a client who has experienced a seizure and has thus progressed to eclampsia. Chapter 19: Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications - Page 688
What to look at with the renal function in preeclampsia?
Cr, UA, albumin
(Preeclampsia) Decreased or increased placental perfusion?
Decreased
What to look at with the liver function in preeclampsia?
Elevated AST, ALT, ALP, LD
Proteinuria in severe preeclampsia?
Greater or equal to 5g in 24hr collection
What to look at with the coagulation in preeclampsia?
PT, PTT, INR, fibrinogen
In mild preeclampsia what will the weight look like?
Weight gain of more than 1.5kg per month in second trimester or more than 0.5kg (1.1lb) per week in 3rd trimester
The nurse is caring for a pregnant woman with diabetes mellitus. Which potential fetal complications should the nurse monitor the client for as she presents for her scheduled visits? Select all that apply. congenital malformations macrosomia fetus with juvenile diabetes smaller than gestational age baby respiratory disorder
congenital malformations macrosomia respiratory disorder Explanation: Potential problems during pregnancy involving maternal diabetes mellitus include fetal death, macrosomia (oversized fetus), a fetus with a respiratory disorder, difficult labor, preeclampsia or eclampsia, polyhydramnios, and congenital malformations. Chapter 20: Nursing Management of the Pregnancy at Risk: Selected Health Conditions and Vulnerable Populations - Page 712
Hormones that cause insulin resistance?
hPL and growth hormone (somatotropin) increase in growth as placenta does causing insulin resistance within last 20 weeks p. 735
During a routine prenatal visit, a client is found to have 1+ proteinuria and a blood pressure rise to 140/90 mm Hg with mild facial edema. The nurse recognizes that the client has which condition? preeclampsia without severe features gestational hypertension preeclampsia with severe features eclampsia
preeclampsia without severe features Explanation: A woman is said to have gestational hypertension when she develops an elevated blood pressure (140/90 mm Hg) but has no proteinuria or edema. If a seizure from gestational hypertension occurs, a woman has eclampsia, but any status above gestational hypertension and below a point of seizures is preeclampsia. A woman is said to have preeclampsia without severe features when she has proteinuria and a blood pressure rise to 140/90 mm Hg, taken on two occasions at least 6 hours apart and mild facial or extremity edema. A woman has progressed to preeclampsia with severe features when her blood pressure rises to 160 mm Hg systolic and 110 mm Hg diastolic or above on at least two occasions 6 hours apart at bed rest (the position in which blood pressure is lowest) or her diastolic pressure is 30 mm Hg above her prepregnancy level. Marked proteinuria, 3+ or 4+ on a random urine sample or more than 5 g in a 24-hour sample, and extensive edema are also present. A woman has passed into eclampsia when cerebral edema is so acute a tonic-clonic seizure or coma has occurred. Chapter 19: Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications - Page 684
Hypertension and vasospasm is due to what in preeclampsia?
-Gradual loss of resistance to angiotensin II -Nitric oxide pathways -Endothelial dysfunction leads to hyperpermeability, hypertension and thrombophilia
(Preeclampsia) Dipstick readon?
1+ (used only if other quant methods are not available
A pregnant client with type 1 diabetes is in labor. The client's blood glucose levels are being monitored every hour and she has a prescription for an infusion of regular insulin as needed based on the client's blood glucose levels. Her levels are as follows: 1300: 105 mg/dL (5.83 mmol/L) 1400: 100 mg/dL (5.55 mmol/L) 1500: 120 mg/dL (6.66 mmol/L) 1600: 106 mg/dl (5.88 mmol/L) Based on the recorded blood glucose levels, at which time would the nurse likely administer the regular insulin infusion? 1300 1400 1500 1600
1500 Explanation: For the laboring woman with diabetes, intravenous (IV) saline or lactated Ringer's is given, and blood glucose levels are monitored every 1 to 2 hours. Glucose levels are maintained below 110 mg/dL (6.11 mmol/L) throughout labor to reduce the likelihood of neonatal hypoglycemia. If necessary, an infusion of regular insulin may be given to maintain this level. The insulin infusion would be given at 1500, based on the blood glucose level being higher than 110 mg/dL (6.11 mmol/L). Chapter 20: Nursing Management of the Pregnancy at Risk: Selected Health Conditions and Vulnerable Populations - Page 710
A primipara at 36 weeks' gestation is being monitored in the prenatal clinic for risk of preeclampsia. Which sign or symptom should the nurse prioritize? A systolic blood pressure increase of 10 mm Hg Weight gain of 1.2 lb (0.54 kg) during the past 1 week A dipstick value of 2+ for protein Pedal edema
A dipstick value of 2+ for protein Explanation: The increasing amount of protein in the urine is a concern the preeclampsia may be progressing to severe preeclampsia. The woman needs further assessment by the health care provider. Dependent edema may be seen in a majority of pregnant women and is not an indicator of progression from preeclampsia to eclampsia. Weight gain is no longer considered an indicator for the progression of preeclampsia. A systolic blood pressure increase is not the highest priority concern for the nurse, since there is no indication what the baseline blood pressure was. Chapter 19: Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications - Page 683
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? Preeclampsia Anemia Hyperthyroidism Gestational diabetes
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. Chapter 20: Nursing Management of the Pregnancy at Risk: Selected Health Conditions and Vulnerable Populations - Page 706
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? Preeclampsia Anemia Hyperthyroidism Gestational diabetes
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. Chapter 20: Nursing Management of the Pregnancy at Risk: Selected Health Conditions and Vulnerable Populations - Page 706
A client tells that nurse in the doctor's office that her friend developed high blood pressure on her last pregnancy. She is concerned that she will have the same problem. What is the standard of care for preeclampsia? Take a low-dose antihypertensive prophylactically. Have her blood pressure checked at every prenatal visit. Monitor the client for headaches or swelling on the body. Take one aspirin every day.
Have her blood pressure checked at every prenatal visit. Explanation: Preeclampsia and eclampsia are common problems for pregnant clients and require regular blood pressure monitoring at all prenatal visits. Antihypertensives are not prescribed unless the client is already hypertensive. Monitoring for headaches and swelling is a good predictor of a problem but doesn't address prevention—nor does it predict who will have hypertension. Taking aspirin has shown to reduce the risk in women who have moderate to high risk factors, but has shown no effect on those women with low risk factors. Chapter 19: Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications - Page 685
Ketoacidosis from uncontrolled hyperglycemia effects on fetus?
Macrosomia from hyperinsulinemia p. 735 Table 20.2
Problems gestational diabetes can cause for neonates?
Macrosomia, hypoglycemia, birth trauma, preclampsia, c-section, anencephaly, microcephaly, congenital heart disease p. 734
A client at 25 weeks' gestation presents with a blood pressure of 152/99 mm Hg, pulse 78 beats/min, no edema, and urine negative for protein. What would the nurse do next? Notify the health care provider Provide health education Assess the client for ketonuria Document the client's blood pressure
Notify the health care provider Explanation: The client is exhibiting a sign of gestational hypertension, elevated blood pressure greater than or equal to 140/90 mm Hg that develops for the first time during pregnancy. The health care provider should be notified to assess the client. Without the presence of edema or protein in the urine, the client does not have preeclampsia. Chapter 19: Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications - Page 683
Which change in insulin is most likely to occur in a woman during pregnancy? enhanced secretion from normal not released because of pressure on the pancreas unavailable because it is used by the fetus less effective than normal
less effective than normal Explanation: Somatotropin released by the placenta makes insulin less effective. This is a safeguard against hypoglycemia. Chapter 20: Nursing Management of the Pregnancy at Risk: Selected Health Conditions and Vulnerable Populations - Page 707