ch 15: pregestational problems

Question 139447Id: 139447

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The nurse is caring for a pregnant woman who admits to cocaine and ecstasy use on a regular basis. The patient states, “Everybody knows that alcohol is bad during pregnancy, but what’s the big deal about ecstasy?” The best response by the nurse is: “Ecstasy:

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Answer

Choice 1 “Can cause a high fever in you and therefore cause the baby harm.”

Rationale 1High body temperature is a side effect of MDMA (ecstasy). Increased body temperature increases fetal oxygen needs, which can lead to hypoxia and subsequent brain and major organ damage.

Answer 1 true

Choice 2“Leads to deficiencies of thiamine and folic acid, which help the baby develop.”

Rationale 2Alcohol, not ecstasy, causes deficiencies of thiamine and folic acid. Folic acid helps prevent neural tube defects.

Answer 2 false

Choice 3“Produces babies with small heads and short bodies with brain function alterations.”

Rationale 3 Cocaine causes these fetal effects, not ecstasy.

Answer 3 false

Choice 4 “Produces intrauterine growth restriction and meconium aspiration.”

Rationale 4 Heroin causes these fetal effects, not ecstasy.

Answer 4 false

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Learning Outcome 1:LO01 - Summarize the effects of alcohol and illicit drugs on the childbearing woman and her fetus/newborn.

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The nurse is doing preconception counseling with a 28-year-old woman with no prior pregnancies. Which of the following statements made by the patient indicates to the nurse that the patient has understood the teaching?

Stimulus

Answer

Choice 1 “I can continue to drink alcohol until I am diagnosed as pregnant.”

Rationale 1Women should discontinue drinking alcohol when they start to attempt pregnancy.

Answer 1 false

Choice 2“I need to stop drinking alcohol completely when I start trying to get pregnant.”

Rationale 2Women should discontinue drinking alcohol when they start to attempt pregnancy.

Answer 2 true

Choice 3 “A beer once a week will not damage the fetus.”

Rationale 3It is not known how much alcohol will cause fetal damage; therefore, alcohol during pregnancy is contraindicated.

Answer 3 false

Choice 4“I can drink alcohol while breastfeeding since it doesn’t pass into breast milk.”

Rationale 4Alcohol passes readily into breast milk; therefore, it should be avoided, or the milk should be pumped and dumped after alcohol consumption.

Answer 4 false

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A woman’s history and appearance suggest drug abuse. The nurse’s best approach would be to:

Stimulus

Answer

Choice 1 Ask the woman directly, “Do you use any street drugs?”

Rationale 1

The best method of dealing with the patient that the nurse suspects of using drugs is to be direct and ask the question in a direct fashion without prejudice, bias, or negative body language. Lack of judgmental attitudes/body language typically results in honest answers.

Answer 1 true

Choice 2 Ask the woman if she would like to talk to a counselor.

Rationale 2 It is the responsibility of the nurse to question the patient.

Answer 2 false

Choice 3Ask some questions about over-the-counter medications and avoid the mention of illicit drugs.

Rationale 3 It is the responsibility of the nurse not to avoid the issue.

Answer 3 false

Choice 4 Explain how harmful drugs can be for her baby.

Rationale 4When talking to patients in a therapeutic manner, it is important not to be threatening or judgmental; an example of the latter behavior would be stating that the drugs will harm the baby.

Answer 4 false

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A 20-year-old woman is at 28 weeks’ gestation. Her prenatal history reveals past drug abuse, and urine screening indicates that she has recently used heroin. The nurse should recognize that the woman is at increased risk for:

Stimulus

Answer

Choice 1 Erythroblastosis fetalis.

Rationale 1Erythroblastosis fetalis is secondary to physiological blood disorders such as Rh incompatibility.

Answer 1 false

Choice 2 Diabetes mellitus.

Rationale 2 Diabetes is an endocrine disorder that is unrelated to drug use/abuse.

Answer 2 false

Choice 3 Abruptio placentae.

Rationale 3 Abruptio placentae is seen more commonly with cocaine/crack use.

Answer 3 false

Choice 4 Pregnancy-induced hypertension.

Rationale 4Women who use heroin are at risk for poor nutrition, anemia, and pregnancy-induced hypertension (or pre-eclampsia).

Answer 4 true

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The patient with insulin-dependent type 2 diabetes and an HbA1c of 5.0% is planning to become pregnant soon. What anticipatory guidance should the nurse provide this patient?

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Answer

Choice 1Insulin needs decrease in the first trimester and increase during the third trimester.

Rationale 1In addition, insulin requirements drop suddenly after delivery of the placenta.

Answer 1 true

Choice 2 The risk of ketoacidosis decreases during the length of the pregnancy.

Rationale 2 The risk of ketoacidosis increases during pregnancy.

Answer 2 false

Choice 3 Vascular disease that accompanies diabetes slows progression.

Rationale 3Vascular disease progresses more rapidly during pregnancy, especially if blood sugar control is not good. Problems such as nephropathy and retinopathy can result.

Answer 3 false

Choice 4 The baby is likely to have a congenital abnormality because of the diabetes.

Rationale 4Infants of diabetic mothers have a 5–10% greater risk of having a congenital abnormality. This risk increases to 20–25% if the HbA1c is over 10%.

Answer 4 false

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Learning Outcome 1:LO02 - Discuss the pathology, treatment, and nursing care of pregnant women with diabetes mellitus.

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A newly diagnosed type 1, insulin-dependent diabetic with good blood sugar control is at 20 weeks’ gestation. She asks the nurse how her diabetes will affect her baby. The best explanation would include:

Stimulus

Answer

Choice 1 “Your baby may be smaller than average at birth.”

Rationale 1Poorly controlled type 1 diabetics who have developed vascular problems will have infants who are small for gestational age (SGA) due to placental insufficiency.

Answer 1 false

Choice 2 “Your baby will probably be larger than average at birth.”

Rationale 2

The infant of a diabetic mother produces excessive amounts of insulin in response to the high blood sugar. This hyperinsulinism stimulates growth (or macrosomia) in the infant because the infant utilizes the glucose in the bloodstream.

Answer 2 true

Choice 3“As long as you control your blood sugar, your baby will not be affected at all.”

Rationale 3The demands of pregnancy will make it difficult for the best of patients to control blood sugar on a regular basis.

Answer 3 false

Choice 4 “Your baby might have high blood sugar for several days.”

Rationale 4Within minutes of delivery, the baby of an insulin-dependent diabetic can begin to have low blood sugar.

Answer 4 false

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A 26-year-old multigravida is 28 weeks pregnant. She has developed gestational diabetes. She is following a program of regular exercise, which includes walking, bicycling, and swimming. What instructions should be included in a teaching plan for this patient?

Stimulus

Answer

Choice 1 “Exercise either just before meals or wait until two hours after a meal.”

Rationale 1 It is best to exercise just after the meal in order to utilize the glucose.

Answer 1 false

Choice 2 “Carry hard candy (or other simple sugar) when exercising.”

Rationale 2A patient should be encouraged to continue any exercise programs in which she already is involved. She should keep hard candy (simple sugar) with her at all times, just in case the exercise induces hypoglycemia.

Answer 2 true

Choice 3 “If your blood sugar is 120 mg/dl, eat 20 g of carbohydrate.”

Rationale 3 A finger stick result of 120 mg/dl is considered to be normal.

Answer 3 false

Choice 4 “If your blood sugar is more than 120 mg/dl, drink a glass of whole milk.”

Rationale 4 Such patients need no additional carbohydrate or protein intake.

Answer 4 false

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A 31-year-old woman who is at high risk for diabetes is at 18 weeks' gestation. During her first antenatal visit, which is the accurate approach to evaluating the patient for diabetes?

Stimulus

Answer

Choice 1Begin serial testing of the patient's serum glucose and HA1c at 24 weeks' gestation.

Rationale 1Women at high risk for type 2 DM should be screened for diabetes as soon as possible.

Answer 1 false

Choice 2If diabetes is diagnosed, consider this condition to be gestational diabetes mellitus (GDM).

Rationale 2Women who are determined to have diabetes at this visit should be diagnosed as having overt diabetes and not GDM.

Answer 2 false

Choice 3Recognize HA1c equal to or greater than 4.5% or a fasting plasma glucose level equal to or greater than 90 mg/dl as being diagnostic of diabetes.

Rationale 3

HA1c equal to or greater than 6.5% would be considered diagnostic as would a fasting plasma glucose level equal to or greater than 126 mg/dl or a 2-hour plasma glucose equal to or greater than 200 mg/dl during an oral glucose tolerance test (OGTT).

Answer 3 false

Choice 4 Conduct screening for type 2 diabetes mellitus as soon as possible.

Rationale 4Women at high risk for type 2 DM should be screened for diabetes as soon as possible.

Answer 4 true

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The pregnant patient at 23 weeks’ gestation has a hemoglobin of 9.5. Which diet choice indicates that teaching has been effective?

Stimulus

Answer

Choice 1 Tofu with mixed vegetables in curry, milk, whole-wheat bun

Rationale 1This diet is high in calcium. The patient has iron-deficiency anemia and requires a high-iron diet.

Answer 1 false

Choice 2 Roast beef, steamed spinach, tomato soup, orange juice

Rationale 2

This patient is anemic and needs iron. This meal contains iron in the beef, folic acid in the spinach, and vitamin C in the tomato soup and orange juice. Vitamin C helps absorption of the iron; folic acid is needed for production of red cells.

Answer 2 true

Choice 3 Pork chop, mashed potatoes and gravy, cauliflower, tea

Rationale 3This meal has a moderate amount of protein, but no vitamin C. The meal containing beef is better.

Answer 3 false

Choice 4 Broiled fish, lettuce salad, grapefruit half, carrot sticks

Rationale 4This meal is high in fiber, low in fat, and moderately high in protein, but low in iron. This patient is anemic and needs iron.

Answer 4 false

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Learning Outcome 1:LO03 - Distinguish among the four major types of anemia associated with pregnancy with regard to signs, treatment, and implications for pregnancy.

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A woman at 30 weeks' gestation and a history including sickle cell anemia presents to the clinic complaining of fever, chills, and diarrhea for three days. What are the most serious potential complications faced by this patient?

Stimulus

Answer

Choice 1 Electrolyte imbalance

Rationale 1While the patient may experience electrolyte imbalance, sickle cell crisis is the most serious potential complication of dehydration and fever.

Answer 1 false

Choice 2 Sickle cell crisis

Rationale 2Dehydration and fever can trigger sickling and crisis; for this reason, maternal infections are treated promptly.

Answer 2 true

Choice 3 Fetal neural tube defects

Rationale 3Fever, chills, and dehydration in the patient with sickle cell anemia are not associated with an increased incidence of neural tube defects.

Answer 3 false

Choice 4 Severe lethargy

Rationale 4While the patient may develop severe lethargy, her greatest risk concerns development of sickle cell crisis.

Answer 4 false

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A patient who is at 18 weeks' gestation has been newly diagnosed with megaloblastic anemia. Which statement by the patient indicates that she understands the teaching?

Stimulus

Answer

Choice 1“I should include fresh leafy green vegetables, red meat, fish, poultry, and legumes in my diet.”

Rationale 1Folic acid, which is used to treat megaloblastic anemia, is readily available in foods such as fresh leafy green vegetables, red meat, fish, poultry, and legumes.

Answer 1 true

Choice 2“Whenever possible, I should boil my vegetables in at least 2 quarts of water.”

Rationale 2Folic acid, which is crucial for inclusion in the diet of patients with megaloblastic anemia, is easily destroyed by overcooking or cooking with large quantities of water.

Answer 2 false

Choice 3 “Megaloblastic anemia is not known to cause any serious risks to my baby.”

Rationale 3Maternal folic acid deficiency has been associated with an increased risk of neural tube defects (NTDs) such as spina bifida, meningomyelocele, and anencephaly in the newborn.

Answer 3 false

Choice 4 “My body makes red blood cells that are smaller than they should be."

Rationale 4In megaloblastic anemia, red blood cells become enlarged and are fewer in number.

Answer 4 false

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The patient at 9 weeks’ gestation has been told that her HIV test was positive. The patient is very upset and tells the nurse, “I didn’t know I had HIV! What will this do to my baby?” The nurse knows teaching has been effective when the patient states:

Stimulus

Answer

Choice 1“I cannot take the medications that control HIV during my pregnancy because they will harm the baby.”

Rationale 1Most of the medications that control HIV progression are safe to take during pregnancy. Antiretroviral medications are recommended during pregnancy to prevent perinatal transmission.

Answer 1 false

Choice 2“My baby will probably be born with anti-HIV antibodies, but that doesn’t mean it is infected.”

Rationale 2Babies of HIV-positive women or women with AIDS are born with maternal anti-HIV antibodies. These antibodies clear over time, and an accurate test can be obtained by 15 months of age.

Answer 2 true

Choice 3“The pregnancy will increase the progression of my disease and will reduce my CD4 counts.”

Rationale 3There is no evidence to indicate that pregnancy increases the progression of HIV/AIDS.

Answer 3 false

Choice 4“The HIV won’t affect my baby, and I will have a low-risk pregnancy without additional testing.”

Rationale 4 Pregnancy affected by HIV/AIDS is considered complicated, and the fetus is monitored closely. Fetal assessments include weekly nonstress tests

beginning at 32 weeks.

Answer 4 false

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Learning Outcome 1:LO05 - Describe acquired immunodeficiency syndrome (AIDS), including care of the pregnant woman with HIV/AIDS, neonatal implications, and ramifications for the childbearing family.

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During her first antepartal visit, a patient who is at 10 weeks' gestation reports that she is HIV-positive. Which statement made by the patient indicates an understanding of the plan of care both during the pregnancy and postpartally?

Stimulus

Answer

Choice 1"I'm supposed to take highly active antiretroviral therapy (HAART), but only during the first trimester."

Rationale 1

Longer duration therapy is preferable to shorter duration approaches, and it is best to start prophylaxis after the first trimester and no later than 28 weeks’ gestation in women who do not require immediate therapy for their own health.

Answer 1 false

Choice 2 "I should not breastfeed my baby."

Rationale 2HIV transmission can occur during pregnancy and through breast milk; however, it is believed that the majority of all infections occur during labor and birth.

Answer 2 true

Choice 3"If I have a cesarean section, there's an increased risk that my HIV will be passed to my baby."

Rationale 3 Cesarean section reduces the transmission of HIV from mother to infant.

Answer 3 false

Choice 4 "When my baby is 2 months old, he or she will be tested for HIV."

Rationale 4Following birth, HIV infection in infants should be diagnosed using HIV virologic assays as soon as possible, with initiation of infant antiretroviral prophylaxis immediately if the test is positive.

Answer 4 false

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A woman is 32 weeks pregnant. She is HIV-positive, but asymptomatic. What would be important in managing her pregnancy and delivery?

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Choice 1 An amniocentesis at 30 and 36 weeks

Rationale 1All invasive procedures that would expose the uninfected infant to the HIV virus are avoided.

Answer 1 false

Choice 2 Weekly nonstress testing beginning at 32 weeks’ gestation

Rationale 2

Patients who are HIV-positive are considered high-risk pregnancies. Therefore, beginning at about 32 weeks, these patients have weekly nonstress tests to assess for placental function and an ultrasound every 2–3 weeks to assess for intrauterine growth retardation (IUGR).

Answer 2 true

Choice 3Application of a fetal scalp electrode as soon as her membranes rupture in labor

Rationale 3All invasive procedures that would expose the uninfected infant to the HIV virus are avoided.

Answer 3 false

Choice 4 Administration of intravenous antibiotics during labor and delivery

Rationale 4Antibiotics would be ineffective for either the mother or the infant who was HIV-positive.

Answer 4 false

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A pregnant woman is married to an intravenous drug user. She had a negative HIV screening test just after missing her first menstrual period. What would indicate that the patient needs to be retested for HIV?

Stimulus

Answer

Choice 1 Hemoglobin of 11 g/dL and a rapid weight gain

Rationale 1 The patient would be anemic and anorexic.

Answer 1 false

Choice 2 Elevated blood pressure and ankle edema

Rationale 2 The patient would have a decrease in blood pressure and no ankle edema.

Answer 2 false

Choice 3 Shortness of breath and frequent urination

Rationale 3Shortness of breath and frequent urination do not indicate a need to retest for HIV.

Answer 3 false

Choice 4 Unusual fatigue and recurring Candida vaginitis

Rationale 4The patient who is HIV-positive would have a suppressed immune system and would experience symptoms of fatigue and opportunistic infections such as Candida vaginitis.

Answer 4 true

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The nurse is reviewing prenatal charts. A patient at 24 weeks has a history of class II heart disease secondary to rheumatic fever. What would the nurse expect to see in the chart?

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Choice 1 Dyspnea and chest pain with mild exertion

Rationale 1Dyspnea and angina with mild exertion are not expected with class II heart disease even during pregnancy, but are symptoms seen in class IV heart disease.

Answer 1 false

Choice 2 Elective cesarean birth scheduled for 37 weeks

Rationale 2Cesarean birth is only undertaken in cardiac patients for fetal or maternal intrapartal indications, not for cardiac reasons alone.

Answer 2 false

Choice 3 Discussed need for labor epidural and vacuum extraction

Rationale 3Lumbar epidural analgesia decreases the stress response during labor, while vacuum extraction or forceps decreases maternal pushing efforts. Both of these decrease stress on the heart during birth.

Answer 3 true

Choice 4 Respiratory rate 28, pulse 110, 3+ pre-tibial edema bilaterally

Rationale 43+ pre-tibial edema is never an expected finding during pregnancy. Pulse over 100 and respiratory rate over 24 are indicators of cardiac decompensation.

Answer 4 false

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Learning Outcome 1:LO06 - Describe the effects of various heart disorders on pregnancy, including their implications for nursing care.

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The prenatal clinic nurse has received four phone calls. Which patient should be called first?

Stimulus

Answer

Choice 1Primip at 28 weeks with history of asthma reporting difficulty breathing and shortness of breath

Rationale 1Asthma exacerbations are most common between 24 and 36 weeks. Asthma attacks can lead to maternal hypoxia, which can lead to fetal hypoxia. This patient is the top priority.

Answer 1 true

Choice 2Multip at 6 weeks with a seizure disorder inquiring what foods are good folic acid sources for her

Rationale 2Women with seizure disorders should be started on folic acid supplements prior to pregnancy, and should continue throughout pregnancy. This patient is not the highest priority.

Answer 2 false

Choice 3Primip at 35 weeks with a positive HBsAG wondering what treatment her baby will receive after birth

Rationale 3

A patient with a positive HBsAG is contagious for hepatitis B. The risk of transmission to the fetus at birth is reduced by bathing the neonate as soon as possible after birth and giving the infant immunoprophylaxis and the first HBsAG vaccine dose. The patient seeking information about what will happen after delivery is a low priority when there are pregnant patients currently experiencing physiologic problems.

Answer 3 false

Choice 4 Multip at 11 weeks with untreated hyperthyroidism describing the onset of vaginal bleeding

Rationale 4

Pregnant women with untreated hyperthyroidism have an increased risk of fetal loss. Vaginal bleeding at 11 weeks could indicate that spontaneous abortion is taking place. But the majority of spontaneous abortions prior to 12 weeks’ gestation are complete and without complications. This patient is not experiencing a normal pregnancy, but the health of both mother and fetus are not in immediate danger.

Answer 4 false

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Learning Outcome 1:LO07 - Compare the effects of selected pregestational medical conditions on pregnancy.

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Question Stem

The patient was found to have hepatitis B surface antigen (HBsAG) early in her pregnancy. The nurse is explaining to the patient what will happen during labor and birth because the patient is contagious for hepatitis B. Which statement by the patient indicates that additional teaching is needed?

Stimulus

Answer

Choice 1 “An internal fetal monitor will be applied as soon as possible during labor.”

Rationale 1 An internal fetal monitor will be avoided.

Answer 1 true

Choice 2 “My baby will get a bath as soon as its temperature is stable.”

Rationale 2

The presence of hepatitis B surface antigen (HBsAG) indicates that the patient is contagious for and capable of transmitting hepatitis B. Perinatal transmission is most likely to occur at the time of birth; thus, measures are taken to prevent exposing the fetus to the mother’s blood and body fluids and to clean the baby’s skin thoroughly of fluids as soon as possible after birth.

Answer 2 false

Choice 3 “Two shots will be given to my baby to prevent transmission of hepatitis B.”

Rationale 3A newborn of a mother with HBsAG will receive an injection of hepatitis B immune globulin and a hepatitis B vaccine injection.

Answer 3 false

Choice 4 “Breastfeeding is a good feeding method for my baby.”

Rationale 4 Breastfeeding is not contraindicated in a patient with HBsAG.

Answer 4 false

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ch 15: pregestational problems

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