Chapter 15:regnancy at Risk: Pre-Existing Conditions

Question 1

1. In assessing the knowledge of a pregestational patient with type 1 diabetes concerning changing insulin needs during pregnancy, a nurse recognizes that further teaching is warranted when the patient 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.”

Answer 1

ANS: A
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.

Question 2

2. A nurse is aware that which is attributable to poor glycemic control before and during early pregnancy?
   a. Frequent episodes of maternal hypoglycemia
   b. Congenital anomalies in the fetus
   c. Polyhydramnios
   d. Hyperemesis gravidarum

Answer 2

ANS: B
Preconception counselling 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, as the decreased food intake by the mother and glucose transfer to the fetus contribute to hypoglycemia.

Question 3

3. In planning for the care of a 30-year-old woman with pregestational diabetes, what does a nurse recognize as 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

Answer 3

ANS: D
Patients with excellent glucose control and no blood vessel disease should have good pregnancy outcomes. The patient`s age is not related to gestational diabetes. Number of years since diabetes was diagnosed is not the most important factor affecting pregnancy outcome. The amount of insulin required prenatally is not the most important factor affecting pregnancy outcome.

Question 4

4. What normal fasting glucose level should the nurse recommend for a woman with pregestational diabetes?
   a. 2.5 to 3.5 mmol/L
   b. 3.8 to 5.2 mmol/L
   c. 5.5 to 7.7 mmol/L
   d. 5.0 to 6.6 mmol/L

Answer 4

ANS: B
Target glucose levels during a fasting period are 3.8 to 5.2 mmol/L. A glucose level of 2.5 to 3.5 mmol/L is low. A glucose level of 5.5 to 7.7 mmol/L is consistent with expected levels with 1-hour postprandial plasma glucose (PG). A glucose level of 5.0 to 6.6 mmol/L is considered normal for a 2-hour postprandial PG.

Question 5

5. A 26-year-old primigravida has come to the clinic for a regular prenatal visit at 12 weeks. They appear thin and somewhat nervous. They report that they eat a well-balanced diet, although their weight is 2.5 kg less than it was at their last visit. The results of laboratory studies confirm that they have a hyperthyroid condition. Based on the available data, the nurse formulates a plan of care. What is the most important aspect of nursing care at this time?
   a. Deficient fluid volume
   b. Decreased nutrition
   c. Anxiety
   d. Disturbed sleep pattern

Answer 5

ANS: B
This patient’s clinical cues include weight loss, which would supports the most important aspect of care at this point is decreased nutrition. There are no clinical signs or symptoms that support a deficient fluid volume. Although the patient is somewhat nervous based on the patient’s other clinical symptoms the most appropriate nursing care would be to focus on the weight loss.

Question 6

6. Which should the nurse know regarding drug testing during pregnancy in Canada?
   a. It is required at the first prenatal visit.
   b. Only those drugs disclosed by the woman are tested for.
   c. There is no legal requirement to test the mother or the newborn child.
   d. Testing is required during the admission to the labour unit.

Answer 6

ANS: C
There is no legal requirement in Canada for a health care provider to test either the mother or the newborn child for the presence of drugs. Testing is not required on the initial prenatal visit. If testing were to occur, all substances would be tested for, not just those disclosed by the mother. Testing is not required before admission to the labour unit.

Question 7

7. What is a nurse aware of in relation to the incidence and classification of diabetes?
   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.

Answer 7

ANS: B
Type 2 diabetes often goes undiagnosed for many years because hyperglycemia develops gradually and often is not severe. Type 2 is 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.

Question 8

8. Metabolic changes throughout pregnancy that affect glucose and insulin in the mother and the fetus are complicated but important to understand. Which is important for a nurse to know?
   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.

Answer 8

ANS: C
Pregnant patients develop increased insulin resistance during the second and third trimesters. Pregnancy exerts a diabetogenic effect on the maternal metabolic status during the latter part of 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 patients are prone to hypoglycemia. Maternal insulin requirements may double or quadruple by the end of pregnancy.

Question 9

9. What should a nurse be aware of with regard to maternal diabetes affecting the pregnant patient and fetus?
   a. Diabetic ketoacidosis (DKA) can lead to fetal death at any time during pregnancy.
   b. Hydramnios occurs less 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.

Answer 9

ANS: A
Prompt treatment of DKA is necessary to save the fetus and the mother. Hydramnios occurs more often in diabetic pregnancies, rather than less often. Infections are more common and more serious in pregnant patients with diabetes. Mild-to-moderate hypoglycemic episodes do not appear to have significant effects on fetal well-being.

Question 10

10. What should a nurse be aware of in relation to diabetes in pregnancy?
    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 central nervous system
    (CNS) defects as infants of mothers that do not have diabetes.
    d. At birth the newborn of a diabetic mother is no longer at any risk.

Answer 10

ANS: B
The most important cause of perinatal loss in diabetic pregnancy is congenital malformations, which account for 30% to 50% of all perinatal loss in pregnancies complicated by diabetes. Even with good control, sudden and unexplained stillbirth remains a major concern. CNS defects (e.g., anencephaly, open spina bifida) are increased 10-fold in infants of mothers with diabetes. The transition to extrauterine life often is marked by hypoglycemia and other metabolic abnormalities.

Question 11

11. A nurse providing care for a patient with Type 1 diabetes understands which about a laboratory test for glycated hemoglobin Alc?
    a. The test is now done for all pregnant patients, not just those with or likely to have
    diabetes.
    b. The test is a snapshot of glucose control at the moment.
    c. The test is completed to evaluate recent glycemic control.
    d. The test is done on the patient’s urine, not her blood.

Answer 11

ANS: C
A laboratory test for glycated hemoglobin Alc would provide evidence of recent glycemic control over time. This is an extra test for diabetic patient, not one done for all pregnant patients. This test defines glycemic control over the previous 4 to 6 weeks. Glycated hemoglobin level tests are done on blood, not urine.

Question 12

12. A patient with asthma is experiencing a postpartum hemorrhage. Which medication would not be used to treat their bleeding because it may exacerbate their asthma?
    a. Oxytocin
    b. Nonsteroidal anti-inflammatory drugs (NSAIDs)
    c. Hemabate
    d. Fentanyl

Answer 12

ANS: C
Prostaglandin derivatives should not be used to treat women with asthma because they may exacerbate symptoms. Oxytocin would be the medication of choice to treat this patient’s bleeding because it would not exacerbate the asthma. NSAIDs are not used to treat bleeding. Fentanyl is used to treat pain, not bleeding.

Question 13

13. A nurse teaches a patient with HIV that which factor increases the risk of mother-to-child perinatal HIV transmission?
    a. Treatment with antiretroviral
    b. Presence of chorioamnionitis
    c. Bottle-feeding after birth
    d. Maternal plasma viral level less than 1000 copies per mL

Answer 13

ANS: B
The presence of chorioamnionitis is a factor that increases the risk of transmission. Treatment will antiretroviral medication decreases the risk. Breastfeeding, not bottle-feeding, increases the risk. A maternal plasma viral level greater than 1000 copies per mL, not less than this, increases the risk.

Question 14

14. Which statement is accurate in providing perinatal care for patients who use substances?
    a. A decision to stop using substances must be made by the family.
    b. Harm reduction practices are not effective with pregnant patients.
    c. Effects of perinatal substance use in pregnancy and postpartum must be reviewed.
    d. Use of community resources for women to eliminate a social bias for perinatal
    care must be avoided.

Answer 14

ANS: C
Reviewing effects of perinatal substance use in pregnancy and postpartum is one recommendation for perinatal care for women who use substances. The decision to stop using substances must be the patient, not their family. Harm-reduction practices are effective with all individuals who use substances. Community resources should not be avoided, rather, the nurse should be familiar with what is available.

Question 15

15. A nurse must be alert for which signs and symptoms of cardiac decompensation when caring for a pregnant patient with cardiac problems?
    a. A regular heart rate and hypertension
    b. An increased urinary output, tachycardia, and slow respirations
    c. Shortness of breath, bradycardia, and hypertension
    d. Frequent cough; crackles; and an irregular, weak pulse

Answer 15

ANS: D
Signs of cardiac decompensation include crackles; an irregular, weak, rapid pulse; generalized edema; and frequent cough. A regular heart rate and hypertension are not generally associated with cardiac decompensation. Tachycardia would indicate cardiac decompensation; increased urinary output and slow respirations would not. Shortness of breath would indicate cardiac decompensation; bradycardia and hypertension would not.

Question 16

16. What should a nurse be aware of with regard to postpartum care of the patient with cardiac disease?
    a. It should be the same as that for any pregnant patient.
    b. It includes rest, stool softeners, and monitoring of the effect of activity.
    c. It includes ambulating frequently, alternating with active range of motion.
    d. It includes limiting visits with the newborn to once per day.

Answer 16

ANS: B
When providing care for a postpartum patient with cardiac disease, bedrest may be ordered with stool softeners, diet, and fluid. Care of the woman with cardiac disease in the postpartum period is tailored to the woman’s functional capacity. The woman will be on bedrest to conserve energy and to reduce strain on the heart. Although the woman may need help caring for the infant, breastfeeding and infant visits are not contraindicated.

Question 17

17. A patient with asthma is experiencing a postpartum hemorrhage. Which medication would be prescribed to treat the bleeding that would not exacerbate the asthma?
    a. Prostaglandin E2
    b. Ergonovine
    c. Hemabate
    d. Methylergonovine

Answer 17

ANS: A
During the postpartum period, patients who have asthma are at increased risk for hemorrhage. If excessive bleeding occurs, prostaglandin (PG) E2 or E1 can be given, although the patient’s respiratory status should be monitored. Because carboprost (15-methyl PGF2 [Hemabate]) and ergonovine and methylergonovine (Methergine) can cause bronchospasm, their use should be avoided.

Question 18

18. Which is important to include in nursing care when caring for a pregnant patient at risk for the development of a thromboembolism?
    a. Monitor the patient for loss of deep tendon reflexes.
    b. Massage their calves when the patient states they have pain.
    c. Apply compression stockings.
    d. Maintain a restriction on fluid intake.

Answer 18

ANS: C
Applying compression stockings would be an appropriate nursing action. Loss of deep tendon reflexes would be related to pre-eclampsia. Massaging the calves is not appropriate because this may dislodge a thromboembolism into the bloodstream (if one is present). Appropriate nursing care would include maintaining adequate hydration, not restricting fluid intake.

Question 19

19. According to statistics, cystic fibrosis occurs once in how many live Caucasian births?
    a. 1500
    b. 2000
    c. 2500
    d. 3200

Answer 19

ANS: D
Cystic fibrosis occurs in about 1 in 3200 live Caucasian births.

Question 20

20. A nurse is aware that with which heart condition pregnancy usually contraindicated?
    a. Pre-existing hypertension
    b. Eisenmenger syndrome
    c. Heart transplant
    d. Aortic valve stenosis

Answer 20

ANS: B
Pregnancy is contraindicated for Eisenmenger syndrome. Women who have had heart transplants are successfully having babies. Pre-existing hypertension is not a contraindication for pregnancy. Aortic valve stenosis is not a contraindication for pregnancy.

Question 21

21. During a physical assessment of an at-risk patient, what is the most likely cause of assessment findings that include generalized edema, crackles at the base of the lungs, and some pulse irregularity?
    a. Euglycemia
    b. Rheumatic fever
    c. Pneumonia
    d. Cardiac decompensation

Answer 21

ANS: D
These symptoms indicate cardiac decompensation. Symptoms of cardiac decompensation may appear abruptly or gradually. Euglycemia is a condition of normal glucose levels. Rheumatic fever can cause heart problems, but it does not present with these symptoms. Pneumonia is an inflammation of the lungs and would not likely generate these symptoms.

Question 22

22. What should a nurse caring for antepartum patients with cardiac conditions be aware of?
    a. Stress on the heart is greatest in the first trimester and the last 2 weeks before
    labour.
    b. Women with class II cardiac disease should avoid heavy exertion and any activity
    that causes even minor symptoms.
    c. Women with class III cardiac disease should get 8 to 10 hours of sleep every day
    and limit housework, shopping, and exercise.
    d. Women with class I cardiac disease need bedrest through most of the pregnancy
    and face the possibility of hospitalization near term.

Answer 22

ANS: B
Class II cardiac disease is symptomatic with ordinary activity. Patients in this category need to avoid heavy exertion and limit regular activities as symptoms dictate. Stress is greatest between weeks 28 and 32, when homodynamic changes reach their maximum. Class III cardiac disease is symptomatic with less than ordinary activity. These patients need bedrest most of the day and face the possibility of hospitalization near term. Class I cardiac disease is asymptomatic at normal levels of activity. These patients can carry on limited normal activities with discretion, although they still need a good amount of sleep.

Question 23

23. What should a nurse be aware of with regard to anemia?
    a. It is the most common medical disorder of pregnancy.
    b. It can trigger reflex bradycardia.
    c. The most common form of anemia is caused by folate deficiency.
    d. Thalassemia is a European version of sickle cell anemia.

Answer 23

ANS: A
Anemia is the most common medical disorder of pregnancy. Combined with any other complication, anemia can result in heart failure. Reflex bradycardia is a slowing of the heart in response to the blood flow increases that occur immediately after birth. The most common form of anemia is iron-deficiency anemia. Both thalassemia and sickle cell hemoglobinopathy are hereditary but not directly related or confined to geographic areas.

Question 24

24. What is the most common neurological disorder accompanying pregnancy?
    a. Eclampsia
    b. Bell palsy
    c. Epilepsy
    d. Multiple sclerosis

Answer 24

ANS: C
The effects of pregnancy on epilepsy are unpredictable. Eclampsia sometimes may be confused with epilepsy, which is the most common neurological disorder accompanying pregnancy. Bell palsy is a form of facial paralysis. Multiple sclerosis is a patchy demyelinization of the spinal cord that does not affect the normal course of pregnancy or birth.

Question 25

25. While providing care to a patient with Marfan syndrome early in their pregnancy, which intervention should the nurse initially anticipate?
    a. Antibiotic prophylaxis
    b. Beta-blockers
    c. Surgery
    d. Regional anaesthesia

Answer 25

ANS: B
Antibiotic prophylaxis is not a form of therapy indicated for Marfan syndrome. Beta-Blockers and restricted activity are recommended as treatment modalities early in the pregnancy. Regional anaesthesia is well tolerated by patients with Marfan syndrome; however, it is not essential to care. Adequate labour support may be all that is necessary if an epidural is not part of the patient’s birth plan. Surgery for cardiovascular changes such as mitral valve prolapse, aortic regurgitation, root dilation, or dissection may be necessary. Mortality rates may be as high as 50% in patients who have severe cardiac disease.

Question 26

26. A nurse is aware that which congenital anomaly may occur with the use of anticonvulsant medication?
    a. Gastroschisis
    b. Congenital heart disease
    c. Diaphragmatic hernia
    d. Intrauterine growth restriction

Answer 26

ANS: B
Congenital anomalies that can occur with antiepileptic drugs (AEDs) include cleft lip or palate, congenital heart disease, urogenital defects, and neural tube defects. Gastroschisis, intrauterine growth restriction, and diaphragmatic hernia are not associated with the use of anticonvulsant medication.

Question 27

27. Which major newborn complication is carefully monitored after the birth of the infant of a diabetic mother? a. Hypoglycemia
    b. Hypercalcemia
    c. Hypobilirubinemia
    d. Hypoinsulinemia

Answer 27

ANS: A
The newborn 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 newborn presents with hyperinsulinemia.

Question 28

28. Nursing intervention for the pregnant diabetic patient is based on the knowledge that the need for insulin
    a. increases throughout pregnancy and the after birth period.
    b. decreases throughout pregnancy and the after birth period.
    c. varies depending on the stage of gestation.
    d. should not change because the fetus produces its own insulin.

Answer 28

ANS: C
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.

Question 29

29. In caring for a pregnant patient with sickle cell anemia, a nurse is aware that signs and symptoms of sickle cell crisis include
    a. anemia.
    b. endometritis.
    c. fever and pain.
    d. urinary tract infection.

Answer 29

ANS: C
Patients with sickle cell anemia have recurrent attacks (crisis) of fever and pain, most often in the abdomen, joints, and extremities. These attacks are attributed to vascular occlusion when RBCs assume the characteristic sickled shape. Crises are usually triggered by dehydration, hypoxia, or acidosis. Patients with sickle cell anemia are not iron deficient. Therefore, routine iron supplementation, even that found in prenatal vitamins, should be avoided in order to prevent iron overload. Patients with sickle cell trait usually are at greater risk for after birth endometritis (uterine wall infection); however, this is not likely to occur in pregnancy and is not a sign of crisis. These patients are at an increased risk for UTIs; however, this is not an indication of sickle cell crisis.

Question 30

1. Which are target blood glucose levels during pregnancy for a 2-hour postprandial plasma glucose? (Select all that apply.)
   a. 3.8 mmol/L
   b. 4.3 mmol/L
   c. 4.8 mmol/L
   d. 5.3 mmol/L
   e. 5.8 mmol/L
   f. 6.3 mmol/L
   g. 6.8 mmol/L

Answer 30

ANS: D, E, F
The target blood glucose level during pregnancy for a 2-hour postprandial plasma glucose is from 5.0 to 6.6 mmol/L.

Question 31

2. Which cardiac diseases have the highest mortality rate and are classified as group III? (Select all that apply.)
   a. Pulmonary hypertension
   b. Endocarditis
   c. Atrial septal defect
   d. Aortic stenosis
   e. Eisenmenger’s syndrome
   f. Bioprosthetic valve

Answer 31

ANS: A, B, E
Group III (mortality rate 25% to 50%) includes pulmonary hypertension, coarctation of the aorta with valvular involvement, complicated Marfan syndrome with aortic involvement, endocarditis, Eisenmenger’s syndrome, and peripartum cardiomyopathy with persistent left ventricular dysfunction. Atrial septal defect and bioprosthetic valve are in group 1, with a mortality rate <1%. Aortic stenosis is in group II, with a mortality care of 5% to 20%.

Question 32

3. Which signs assessed in a pregnant patient are indicative of cardiac decompensation? (Select all that apply.)
   a. Frequent cough
   b. Difficulty breathing
   c. Bradycardia
   d. Tachypnea
   e. Generalized edema
   f. Increased energy

Answer 32

ANS: A, B, D, E
Frequent cough, difficulty breathing, tachypnea (>25 breaths/min), and generalized edema are all possible signs of cardiac decompensation. The patient will exhibit increasing fatigue, not increased energy. Rapid pulse, not bradycardia, is a sign of cardiac decompensation.

Question 33

4. Congenital anomalies can occur with the use of antiepileptic drugs (AEDs), including (Select all that apply.)
   a. cleft lip.
   b. congenital heart disease.
   c. neural tube defects.
   d. gastroschisis.
   e. diaphragmatic hernia

Answer 33

ANS: A, B, C
Congenital anomalies that can occur with AEDs include cleft lip or palate, congenital heart disease, urogenital defects, and neural tube defects. Gastroschisis and diaphragmatic hernia are not associated with the use of AEDs.

Question 34

6. Autoimmune disorders often occur during pregnancy because a large percentage of patients with an autoimmune disorder are of childbearing age. Identify all disorders that fall into the category of collagen vascular disease. (Select all that apply.)
   a. Multiple sclerosis
   b. Systemic lupus erythematosus
   c. Antiphospholipid syndrome
   d. Rheumatoid arthritis
   e. Myasthenia gravis

Answer 34

ANS: B, C, D, E
Multiple sclerosis is not an autoimmune disorder. This patchy demyelinization of the spinal cord may be a viral disorder. Autoimmune disorders (collagen vascular disease) make up a large group of conditions that disrupt the function of the immune system of the body. They include those listed, as well as systemic sclerosis.

Question 35

1. Achieving and maintaining euglycemia comprise the primary goals of medical therapy for the pregnant patient with diabetes. These goals are achieved through a combination of diet, insulin, exercise, and blood glucose monitoring. The target blood glucose levels 1 hour after a meal should be .

Answer 35

ANS:
5.5 to 7.7 mmol/L
Target levels of blood glucose during pregnancy are lower than nonpregnant values. Accepted fasting levels are between 3.8 and 5/2 mmol/L, and 1-hour postmeal levels should be between 5.5 to 7.7 mmol/L. Two-hour postmeal levels should be between 5.5 and 6.6 mmol/L.

Question 36

A nurse is preparing to teach an antepartum patient with gestational diabetes the correct method of administering an intermediate acting insulin (NPH) with a short-acting insulin (regular). In the correct order from 1 through 6, match the step number with the action that the nurse would take to teach the patient self-administration of this combination of insulin.
a. Without adding air, withdraw the correct dose of NPH insulin.
b. Gently rotate the insulin to mix it, and wipe the stopper.
c. Inject air equal to the dose of NPH insulin into the vial, and remove the syringe.
d. Inject air equal to the dose of regular insulin into the vial, and withdraw the
medication.
e. Check the insulin bottles for the expiration date.
f. Wash hands.
1. Step 1
2. Step 2
3. Step 3
4. Step 4
5. Step 5
6. Step 6

Answer 36

1. ANS: F
2. ANS: E
3. ANS: B
4. ANS: C
5. ANS: D
6. ANS: A