HESI CASE STUDY

GESTATIONAL DIABETES

1.How should the nurse record Amanda's obstetrical history using the G-T-P-A-L designation? A) 3-2-0-1-3.INCORRECTThis does not reflect the client's obstetrical history.

 B) 3-1-1-1-2.INCORRECTThis does not reflect the client's obstetrical history.

 C) 4-1-1-1-3.CORRECTGravidity [G] is defined as the number of times pregnant, including the current pregnancy. Term [T] is defined as any birth after the end of the 37th week, and preterm [P] refers to any births between 20 and 37 weeks. Both term and preterm describe liveborn and stillborn infants. Abortion [A] is any fetal loss, whether spontaneous or elective, up to 20 weeks gestation. Living [L] refers to all children who are living at the time of the interview. Multiple fetuses such as twins, triplets, and beyond are treated as one pregnancy and one birth when recording the GTPAL. Amanda's GTPAL is 4 (pregnancies counting current one) - 1 (infant born at 39 weeks) - 1 (twins born at 35 weeks) - 1 (spontaneous abortion at 9 weeks) - 3 (each twin and the singleton, all living).   

 D) 4-2-1-0-2.INCORRECTThis does not reflect the client's obstetrical history.

The nurse notes that Amanda's fasting 1 hour glucose screening level, which was done 2 days previously, is 158 mg/dl.

2.The nurse recognizes that what information in the client's history supports a diagnosis of gestational diabetes? A) Maternal great-aunt has insulin dependent (Type 1) diabetes.INCORRECTFamily history of diabetes is not considered a risk factor unless it is a first degree relative.

 B) Youngest child weighed 4300 grams at 39 weeks gestation.

CORRECTBirth of an infant over 9 pounds (~ 4.1 kg or 4100 grams) is a risk factor for gestational diabetes. Other risk factors include maternal age older than 25, obesity, history of unexplained stillborn, family history of Type 1 diabetes in a first-degree relative, strong family history of Type 2 diabetes, and history of gestational diabetes in a previous pregnancy. Ethnic groups at increased risk include Hispanic, Native-American, Asian, and African-American.

 C) Trace of protein noted in urine specimen at last prenatal visit.INCORRECTA trace of protein is normal during pregnancy and does not indicate that the client is at risk for gestational diabetes.

 D) Client is 64 inches tall and weighed 134 pounds prior to pregnancy.INCORRECTThis falls within the normal category for Body Mass Index (BMI) and does not constitute a risk for gestational diabetes.

Further Glucose Screening

Amanda is scheduled for a 3 hour oral glucose tolerance test in 5 days, and is told to arrive at the lab at 8:30 am. Amanda asks if there are any special instructions for the test in addition to fasting for 8 hours immediately prior to the test.

3.Which instruction should the nurse give the client? A) Only coffee or tea is allowed once the fasting level has been drawn.INCORRECTThe client should refrain from eating or drinking anything during the test, although small sips of water are acceptable if the client is very thirsty. In addition, caffeine in any form should be avoided because it tends to increase glucose levels.

 B) Follow an unrestricted diet and exercise pattern for at least 3 days before the test.CORRECTBy following an unrestricted diet (including at least 150 g of carbohydrates) and regular exercise patterns, the test is a true determination of the body's ability to handle the glucose load given after the fasting blood glucose is drawn. 

 C) Write down questions and call the laboratory for instructions the day before the test.INCORRECTThe nurse should give pre-test instructions and answer any questions the client might have.

 D) Smoking in moderation is allowed up until the time the test begins.

INCORRECTSmoking should be avoided at least 12 hours before, and then during the test due to the risk of false elevations in blood sugar level. In addition, smoking during pregnancy puts the fetus at risk for intrauterine growth restriction and other problems.

Amanda asks the nurse why she wasn't tested for gestational diabetes until she was almost 28 weeks gestation.

4.The nurse's response should be based on the understanding of which normal physiologic change of pregnancy? A) Maternal insulin crosses the placenta to regulate fetal glucose levels throughout pregnancy.INCORRECTMaternal glucose, not insulin, crosses the placenta through the process of carrier-mediated facilitated diffusion.

 B) In the first trimester, estrogen and progesterone cause an increase in maternal fasting glucose levels.INCORRECTIncreasing levels of estrogen and progesterone in the first trimester stimulate the pancreas to increase insulin production, resulting in decreased blood glucose levels.

 C) Hormonal changes in the second and third trimesters result in increased maternal insulin resistance.CORRECTIncreased levels of hormones increase insulin resistance because they act as insulin antagonists. This serves as a glucose-sparing mechanism to ensure an adequate glucose supply to the fetus. While most pregnant women's bodies are able to handle this insulin resistance, women with gestational diabetes cannot and, therefore, demonstrate an impaired tolerance to glucose during pregnancy and develop hyperglycemia.

 D) Fetal insulin production increases each trimester, forcing the mother's body to produce more glucose.INCORRECTFetal insulin production begins at around 10 weeks gestation and insulin is secreted at levels that are adequate for utilization of the glucose obtained from the mother.

Interdisciplinary Client Care

Amanda's 3 hour Oral Glucose Tolerance Test indicates that she does have gestational diabetes. The RN phones Amanda and arranges for her to meet with the CNM and perinatologist, as well

as an RN diabetes educator and a registered dietician (RD) the next day. The perinatologist and CNM discuss gestational diabetes with Amanda and after seeking input from Amanda, outline their suggested plan of care, which includes dietary control and glucose self-monitoring. After the perinatologist and CNM leave, Amanda appears confused and asks the RN, "Does this mean I will always have diabetes?"

5.Which response should the nurse give to the client? A) "You will need to be periodically evaluated for Type 2 diabetes for the rest of your life."CORRECTThe woman with gestational diabetes is at increased risk for developing Type 2 diabetes later in life. Carbohydrate intolerance should be evaluated 6 to 12 months after pregnancy, if bottle-feeding, or after breastfeeding has been stopped, and repeated at regular intervals as part of well-woman care. Women with gestational diabetes should be encouraged to lose weight (if overweight) and to exercise to reduce this risk.

 B) "There should be no problem as long as you do not have to use insulin during this pregnancy."INCORRECTThis statement does not accurately answer Amanda's question.

 C) "There is no need to talk about this now. We'll discuss it at your first postpartum visit."INCORRECTThe RN should answer Amanda's question.

 D) "Tell me what worries you about the possibility of developing Type 2 diabetes after your pregnancy ends."INCORRECTWhile it is important to elicit client concerns, this does not answer Amanda's question.

After all her questions are answered, Amanda is scheduled for a return visit with the CNM in 1 week, and is escorted to the office of the registered dietician (RD). The RD discusses the need to control carbohydrates while maintaining an appropriate carbohydrate-protein-fat ratio to promote consistent weight gain (based on the woman's body mass index), prevent ketoacidosis, and encourage normoglycemia (euglycemia). Amanda is then introduced to the RN diabetes educator. She asks the nurse to clarify what the RD told her about the content and timing of her meals.

6.Which response should the nurse give to the client? A) Eliminate the bedtime snack if heartburn develops after eating.INCORRECT

A substantial bedtime snack is necessary to prevent hypoglycemia during the night.

 B) Choose complex carbohydrates that are high in fiber content.CORRECTThe starch and proteins in high-fiber complex carbohydrates, such as whole grains, beans, fresh fruits, and vegetables help regulate the blood glucose as a result of a more sustained glucose release over time. In addition, meals and snacks should be eaten on time and never skipped in order to promote sustained glucose release and decrease the risk of hyper and hypoglycemic episodes.

 C) Increase the percentage of protein in the diet if anemia develops.INCORRECTAlthough many sources of protein do contain iron, the ratio of carbohydrates, proteins, and fats should not be altered if anemia develops. Anemia can be corrected by taking daily prescribed iron supplements.

 D) Vary timing of meals and snacks based on individual preferences.INCORRECTWhile food choices and numbers of snacks (2 to 4) can be based on individual preferences, meals and snacks should be eaten on time.

The RN diabetes educator makes a plan of care to teach Amanda to monitor her glucose levels. The RN diabetes educator discusses the use of self-glucose monitoring and gives Amanda verbal and written guidance about optimal glucose levels at each glucose testing point throughout the day. The nurse also provides instruction about calibration of the glucose monitor, fingerstick technique, and use of the monitor for testing. After reviewing the instructions and a successful return demonstration, the diabetes educator and Amanda agree to meet after Amanda's prenatal appointment to follow-up on today's teaching/learning. 

7.Which fingerstick blood glucose (FSBG) testing protocol should the diabetes educator recommend for Amanda? A) Only if symptoms of hypoglycemia or hyperglycemia occur.INCORRECTThis pattern of FSBG testing does not accurately identify if the prescribed diet is promoting euglycemia.

 B) Prior to breakfast (fasting) and 2 hours after each meal.CORRECTThis protocol will identify if the prescribed diet is promoting euglycemia, and the record obtained from it will allow the healthcare provider and RD to make changes in the plan of care as

needed. 

 C) Before and 2 hours after all meals, at bedtime, and during the night.INCORRECTThis is the protocol for FSBG testing for the woman with pregestational (Type 1 or Type 2) diabetes. In addition, the client with pregestational diabetes will test PRN if symptoms of hypoglycemia or hyperglycemia occur.

 D) Once daily until glucose levels are stabilized, then weekly.INCORRECTThis pattern of FSBG testing does not accurately identify if the prescribed diet is promoting euglycemia, especially at the onset of treatment.

A Complication Occurs

Amanda manages her gestational diabetes with diet. She experiences a few episodes of postprandial hyperglycemia, but does not have to go on insulin. At her 36 week prenatal visit, the CNM assesses Amanda and finds that there is no increase in fetal growth since the week before. When questioned further, Amanda tells the CNM that the infant has seemed to "slow down" a little the last few days. After consultation with the perinatologist, a biophysical profile (BPP) is scheduled and Amanda is admitted to the hospital's antepartum unit.The antepartum RN performs a nonstress test (NST) as part of the BPP.

8.The nurse recognizes which fetal heart rate (FHR) changes indicate a reactive nonstress test? A) Persistent late decelerations associated with three uterine contractions, lasting 40 to 60 seconds each in a 10 minute period.INCORRECTThis describes a positive contraction stress test.

 B) An increase in the FHR baseline to 170 beats per minute, lasting for at least 20 minutes.INCORRECTThis describes fetal tachycardia.

 C) Marked FHR variability in response to contractions caused by nipple stimulation.INCORRECTThis is often seen as a response to uterine hyperstimulation or mild fetal hypoxemia, but is not part of the non-stress test.

 D) Two episodes of acceleration (> 15 beats/minute, lasting > 15 seconds) related to fetal movement in a 20 minute period.CORRECT

This describes a reactive non-stress test. The test is based on the premise that the normal fetus with an intact central nervous system (CNS) will produce accelerations of the fetal heart rate in response 90% of gross fetal body movements. When used as part of the BPP, a reactive test is worth 2 points, and a nonreactive test is worth 0 points.

Amanda has a Non-reactive Non-stress Test. She is taken to the ultrasound department for completion of the BPP and her total score is 6 (Fetal Breathing Movements = 2, Gross Body Movements = 0, Fetal Tone = 2, Non-reactive Non-stress Test = 0, and Qualitative Amniotic Fluid Volume = 2). Based on this score, the perinatologist recommends an amniocentesis be completed to assess for lung maturity prior to making a decision whether to induce delivery for Amanda the next day. 

9.Prior to the amniocentesis, which action should the nurse take first? A) Administer Rh immune globulin (RhoGAM) if client is Rh negative.INCORRECTThis will be done after the amniocentesis.

 B) Assist the client to the bathroom and ask her to empty her bladder.CORRECTIn late pregnancy, this should be done first to decrease the risk of accidental bladder puncture during the procedure. In early pregnancy the bladder should be full when an amniocentesis is done for genetic studies.

 C) Apply the external fetal monitor to evaluate uterine contractility.INCORRECTThis will be done immediately after the procedure to assess for uterine irritability. Fetal heart rate will also be assessed using external monitoring.

 D) Clean the abdomen with betadine solution and sterile 4 by 4s.INCORRECTAnother action must be done prior to prepping the abdomen for the procedure.

Amanda and her fetus are monitored for 2 hours after the procedure and display no adverse effects so the external fetal monitor is discontinued. The amniocentesis reveals fetal lung maturity and an induction is scheduled for the next morning. At 2 a.m. Amanda complains of increased uterine discomfort. She is contracting every 10 minutes and while the antepartum nurse is in the room, Amanda's membranes rupture spontaneously.     

10.Which action by the nurse takes priority? A) Notify the CNM and perinatologist of the changes in Amanda's status.INCORRECTAlthough this will be done, it is not the priority action.

 B) Transfer Amanda to the labor-delivery-recovery (LDR) suites.INCORRECTAlthough this will be done, it is not the priority action.

 C) Reapply the external fetal monitor to evaluate the fetal heart rate.CORRECTThe response of the fetus to the rupture of the membranes should be evaluated immediately due to the risk of cord prolapse. The nurse will also assess and document the color, amount, viscosity, and odor of the amniotic fluid.   

 D) Start an intravenous line using an 18 gauge or larger intravenous catheter.INCORRECTAlthough this will be done, it is not the priority action.

Labor Medications

Amanda is transferred to the labor-delivery-recovery (LDR) suite. A vaginal examination is done. The nurse determines she is 3 cm dilated, 40% effaced, and the fetal head is at -1 station. The external monitor shows that contractions are occurring every 4 minutes, last 70 seconds, and the nurse palpates the quality as strong. The fetal heart rate shows a reassuring pattern. A fingerstick blood glucose (FSBG) is done on admission. The result is 138 so the perinatologist prescribes an intravenous insulin drip. Amanda also receives maintenance IV fluids of D5LR at 125 ml/hr. Should a bolus be needed, Lactated Ringer's will be used.The perinatologist prescribes 25 units of regular human insulin in 250 ml of normal saline started at 1 unit per hour with hourly dose titration to maintain FSBG between 70 and 90 mg/dl.

11.At what rate should the nurse initially set the intravenous pump? A) 1 ml/hr.INCORRECTPlease recalculate.

 B) 10 ml/hr.CORRECTRatio and proportion method:

25 u/250 ml = 1 u/X mlCross-multiply: 25X = 250Therefore, X = 250/25 = 10 ml/hour

Dimensional analysis method: 25 u × 1 u/1 hr = 10 u/hour.

 C) 25 ml/hr.INCORRECTPlease recalculate.

 D) 100 ml/hr.INCORRECTPlease recalculate.

Amanda's husband arrives to be her labor coach and is surprised to learn that Amanda needs IV insulin and is being so closely monitored. He tells the labor nurse he vaguely remembers the perinatologist discussing the possible need for insulin at a prenatal visit, but is unclear as to why the blood sugar is being maintained between 70 and 90 mg/dl.

12.The nurse's response should be based on what information? A) More insulin will be available for fetal use via placental transfer.INCORRECTMaternal insulin (endogenous or exogenous) does not cross the placenta because the insulin molecule is too large.

 B) A glucose level over 90 to 100 puts the client at risk for infection in labor.INCORRECTWhile an infection does put a woman at risk for developing ketoacidosis, a high glucose level in labor does not predispose the client to infection.

 C) An elevated glucose in labor increases the risk of neonatal hypoglycemia.CORRECTMaternal glucose crosses the placenta and the fetus responds by making insulin. Over time, hyperplasia of the fetal pancreas occurs with subsequent hyperinsulinemia. When the maternal source of glucose disappears at delivery, the neonate's blood glucose level decreases rapidly in the presence of fetal hyperinsulinemia.

 D) Maintaining euglycemia in labor decreases the need for insulin postpartum.INCORRECTWhile insulin requirements decrease in the postpartum period, it is because the major source of insulin resistance, the placenta, is gone. This occurs regardless of the level of glycemic control in

the intrapartum period.

Two hours later, Amanda is 6 cm dilated. She requests pain medication to "take the edge off" the contractions, but does not want an epidural. The nurse phones report to the perinatologist and receives a prescription for butorphanol tartrate (Stadol) 1 mg IV.

13.Before giving the medication, what assessment information is most important for the nurse to validate with the laboring client? A) Past or present history of opioid dependence.CORRECTStadol is an opioid agonist-antagonist. Respiratory depression, nausea, and vomiting occur less often with this group of drugs when compared to opioid agonists. However, because Stadol also acts as an antagonist, it is not suitable for women with a history of opioid dependence because it can precipitate withdrawal symptoms (abstinence syndrome) in both the mother and neonate.

 B) Length of all previous labor experiences.INCORRECTAlthough opioids should be used cautiously in women with histories of rapid labor due to the risk of neonatal respiratory depression if the medication is given to the mother too close to the time of birth, another assessment is more important.

 C) Herbal preparation use during pregnancy.INCORRECTSeveral herbs, including chamomile, kava, skullcap, hops, and valerian can increase CNS depression if used concomitantly with Stadol. However, another assessment is more important.

 D) Previous use of analgesia or anesthesia in labor.INCORRECTWhile it is important to know what types of analgesia and anesthesia the client has used in the past, including efficacy and side effects, another assessment is more important.

Legal Issues

Amanda tells the nurse that she would like to receive one-half of the prescribed dose of butorphanol tartrate (Stadol) because the last time she was given that medication she felt like she was floating, and then experienced some confusion.

14.What should the nurse do? A) Administer one-half of the dose as requested.

INCORRECTThis is not within the RN's scope of practice.

 B) Tell the client that she must take the whole dose.INCORRECTThe client has the right to request a lower dose or refuse the medication.

 C) Request that the provider change the prescription.CORRECTThe nurse should consult the healthcare provider if he/she believes a prescription should be altered. The nurse cannot reduce a medication dose without consulting the provider, even at the client's request.

 D) Substitute a medication with fewer side effects.INCORRECTThis is not within the RN's scope of practice.

Amanda receives the analgesic and relief is obtained. Within 30 minutes she has progressed to 8 cm dilation, is fully effaced, and the fetus is at a 0 station.The nurse caring for Amanda is called away from the bedside to admit a new client who has come in with complaints of painless vaginal bleeding at 29 weeks gestation. The nurse is concerned that the care of Amanda, who is entering transition, and the new client, will be compromised if the nurse has to care for both clients. The nurse asks the charge nurse to assign someone else to the new client until after Amanda gives birth. The charge nurse refuses, telling the nurse that "there just isn't anyone else."

15.What should the nurse do next? A) Care for both of the clients.INCORRECTThis increases the risk of compromised care for both clients.

 B) Call the clients' healthcare provider.INCORRECTThe nurse should take another action first.

 C) Contact the nursing supervisor. CORRECTThis is appropriate use of what is known as the "chain of command." If an RN has a problem, she should first discuss it with the charge nurse. If the nurse is still concerned, the next step is to contact the nursing supervisor. Depending on the supervisor's response, the nurse may or may not need to go "up" the chain of command.

 D) Refuse to care for either client.INCORRECTThis could constitute client abandonment.

The nursing supervisor speaks with the RN and charge nurse. The situation is resolved by having the charge nurse admit the new patient while the RN is helping Amanda throughout transition and birth. An on-call RN is called and will assume care of the new client.

Care During Birth

Amanda dilates quickly to 10 cm and feels a strong urge to push. The fetal heart rate continues to be reassuring with a baseline of 145 and moderate variability present. The nurse briefly reviews pushing techniques with Amanda and her husband and notifies the CNM and perinatologist of Amanda's progress. After three cycles of open-glottis pushing, the baby's head is crowning.The head is born easily over an intact perineum, but does rotate externally and retracts back against the perineum. The nurse and perinatologist recognize these signs as an indication of shoulder dystocia. 

16.What should the nurse do immediately? A) Notify the operating room to prepare for a cesarean section.INCORRECTPushing the head back into the vagina and performing a STAT cesarean (Zavanelli's maneuver) is the last option used for completing the birth of the fetus.

 B) Apply external pressure to the uterine fundus.INCORRECTFundal pressure further wedges the shoulder under the symphysis pubis and may cause injury to mother and fetus.

 C) Administer 0.25 mg terbutaline (Brethine) subcutaneously.INCORRECTThis medication would relax the uterus, which is not needed at this time.

 D) Reposition the client using McRobert's maneuver.CORRECTThe nurse should assist the woman in flexing and abducting the maternal hips, positioning the maternal thighs up onto the maternal abdomen. This position decreases the angle of the pelvic inclination, rotates the symphysis pubis toward the maternal head, and causes the sacrum to straighten, freeing the shoulder. This maneuver is often combined with suprapubic pressure,

which also helps free the shoulder from under the symphysis pubis. 

As the nurse performs the intervention, the perinatologist cuts an episiotomy, Amanda pushes, and the male infant is born. He weighs 9 lbs 9 ounces and has an Apgar of 7 at 1 minute and 9 at 5 minutes, requiring only stimulation and flow-by oxygen for 1 minute. The nurse performs a physical assessment of the newborn prior to giving him to Amanda to breastfeed. 

17.The nurse should recognize which newborn behavior indicates that the infant has suffered a complication from the shoulder dystocia? A) Unilateral absence of the Moro reflex.CORRECTThis behavior is indicative of a fractured clavicle, which is a common complication of shoulder dystocia. Newborn fractures heal rapidly and immobilization is accomplished with slings, splints, or sometimes simple swaddling.     

 B) One eye remains open when crying.INCORRECTThis is indicative of facial paralysis (palsy), which is not a common sequellae of shoulder dystocia.

 C) Positive Babinski reflex bilaterally.INCORRECTThis is a normal response in the newborn.

 D) Presence of caput succedaneum.INCORRECTWhile this may occur in the infant who has shoulder dystocia, it is a common finding in the newborn and has no pathological significance.

The newborn's assessment is normal. Amanda breastfed her other children, but is concerned because she read that infants of diabetic mothers are at greater risk for jaundice than infants of non-diabetics. She is also worried about the infant developing hypoglycemia.

18.What should the nurse recommend to Amanda in regard to infant feeding? A) The infant requires formula to prevent hypoglycemia and jaundice.INCORRECTThere is a better feeding alternative.

 B) The newborn needs breast milk and 5% dextrose water.INCORRECTThere is a better feeding alternative.

 C) Breastfeeding should be initiated immediately and done on demand.CORRECTBreastfeeding that commences early and is done on demand (breastfeeding infants generally feed more often than formula-fed infants) helps decrease the risk of hypoglycemia and jaundice. Supplements of water and/or formula are not needed.

 D) A mixture of breastmilk and formula will prevent complications.INCORRECTThere is a better feeding alternative.

Management Issues

Two hours after her delivery, the labor and delivery nurse notifies the postpartum charge nurse that Amanda and her son will be transferred to the unit. The charge nurse is also notified that three other mother-infant couplets will be transferred at about the same time. The postpartum unit is staffed with a new graduate RN, who has completed orientation, a RN with 3 years experience, a RN with 10 years experience, and a Licensed Practical Nurse (LPN) with 20 years experience.

19.Which patient should the charge nurse assign the LPN? A) Amanda who is a gestational diabetic and had a problem breastfeeding.INCORRECTSince Amanda has gestational diabetes, was on insulin, and had a problem breastfeeding the charge nurse should assign an experienced RN to care for the mother-infant couplet.

 B) A multigravida who had an uncomplicated term delivery and is breastfeeding.CORRECTOnce the initial assessment is done, the LPN is qualified to care for this patient because there are no complications expected.

 C) A primigravida who had a cesarean delivery 4 hours ago and is bottle feeding.INCORRECTThe new graduate who has finished with orientation is qualified to take care of this mother-infant couplet.

 D) A primigravida who is 12 hours posteclamptic seizure and is bottle feeding.INCORRECT

The woman who is postseizure requires the RN with the greatest experience to monitor the postpartum period and deal with psychosocial issues.

As the charge nurse is going down the hall to tell the nurses about the new admissions, she hears one of the nurses giving misinformation about the Rubella vaccine to a client and her husband.

20.What action should the charge nurse take? A) Interrupt the nurse and give the client the correct information immediately.INCORRECTThis action may be perceived as demeaning to the nurse.

 B) Speak to the nurse in the hall so the nurse can correct the information for the client.CORRECTThe nurse who gave the misinformation corrects the mistake with the client and her husband. This avoids embarrassing the nurse and lets the nurse preserve the relationship with the client and her husband as well as correct misinformation.

 C) Ask the education department to schedule an inservice on Rubella vaccine.INCORRECTWhile this may need to be done if the misinformation is wide-spread on the unit, another action is better initially.

 D) Complete an adverse occurrence report and make the nurse sign it.INCORRECTAn adverse occurrence report should be completed if an unexpected event that is potentially harmful occurs in the care of a client. This situation can be resolved without risk or harm to the client so there is no need to complete an adverse occurrence report.

The nurse who gave the misinformation corrects the mistake with the client and her husband. Labor and delivery transfers the clients, and their care is assumed by the Mother-Baby nurses without incident.

Mother-Baby Care

Labor and delivery transfers the clients and their care is assumed by the Mother-Baby nurses without incident. The Labor and Delivery nurse reports to the postpartum nurse that Amanda ambulated to the bathroom without difficulty and voided just prior to being transferred. An initial assessment is completed by the postpartum nurse.

21.

Where will the nurse expect to palpate the uterine fundus? A) Midline at the umbilicus.CORRECTThe uterine fundus should be midline at the umbilicus after birth for 24 hours. A fundus elevated above the umbilicus or shifted to the left or right may indicate blood in the uterus or a full bladder.   

 B) Midline 2 cm above the umbilicus.INCORRECTThis is not the expected position of the fundus at 2 hours post birth.

 C) Shifted left at the umbilicus.INCORRECTThis is not the expected position of the fundus at 2 hours post birth.

 D) Shifted right 4 cm below umbilicus.INCORRECTThis is not the expected position of the fundus at 2 hours post birth.

Amanda asks the nurse why the insulin was discontinued after the baby was born and asks if she will have to take the medication as a "shot" or "pills" now.

22.The nurse's response should be based on which information? A) Most women with gestational diabetes return to normal glucose levels after birth.CORRECTBecause the major source of insulin resistance, the placenta, is gone after birth, the woman with gestational diabetes usually returns to normal glucose levels and requires no insulin, oral hypoglycemics, or diabetic diet. Breastfeeding also decreases insulin needs because of the carbohydrates used in human milk production.

 B) Sliding scale insulin will be needed for 6 weeks postpartum.INCORRECTThis does not describe the normal postpartum course for the woman with gestational diabetes.

 C) Breastfeeding increases the need for insulin so an insulin pump will be applied.INCORRECTThis does not describe the normal postpartum course for the woman with gestational diabetes.

 D) Oral hypoglycemics will be started as soon as the client is eating a regular diet.INCORRECTThis does not describe the normal postpartum course for the woman with gestational diabetes.

Two days later, Amanda and the infant are both stable and breastfeeding is well established. The nurse is preparing discharge teaching and notes that Amanda has chosen to use the Progestin-only birth control pill beginning at 6 weeks postpartum and that she plans to breastfeed exclusively for at least 6 months.

23.Which information is most important for the nurse to discuss concerning the use of this medication? A) Irregular vaginal bleeding (breakthrough bleeding) is not unusual when using this medication and usually lessens over time.INCORRECTAlthough this is true, it is not the most important information for the nurse to discuss.

 B) If a dose is taken more than 3 hours late, a backup method of birth control must be used for the next 48 hours.CORRECTBecause this medication contains such a low dose of Progestin, it should be taken at exactly the same time every day and if this is not done, the risk of pregnancy increases at a much greater rate than if one misses a combined estrogen-Progestin pill.