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Chapter 11 High Risk Perinatal Care:
Preexisting Conditions
Which is the ideal treatment for severe unmanageable hyperthyroidism in a patient who is pregnant? 1 .Radioactive iodine 2 .Subtotal thyroidectomy 3 .Methimazole (Tapazole) 4 .Propylthiouracil (Propacil - ✔✔ 2 A subtotal thyroidectomy is prescribed for a pregnant patient with severe hyperthyroidism if the drug therapy proves toxic. Oral methimazole and propylthiouracils are prescribed for hyperthyroidism but may be ineffective in severe cases. Radioactive iodine is not used to treat hyperthyroidism in pregnant patients, because it may destroy the fetus's thyroid gland. Which factor is known to increase the risk of gestational diabetes mellitus? 1 .Previous birth of large infant 2 .Maternal age younger than 25 3 .Underweight before pregnancy 4 .Previous diagnosis of type 2 diabetes mellitus - ✔✔ 1 Previous birth of a large infant suggests gestational diabetes mellitus. A woman younger than 25 is not at risk for gestational diabetes mellitus. Obesity (greater than 90 kg or 198 lb) creates a higher risk for gestational diabetes. The person with type 2 diabetes mellitus already has diabetes and will continue to have it after pregnancy. Insulin may be required during pregnancy because oral hypoglycemia drugs are contraindicated during pregnancy.
Test-Taking Tip: Be alert for details. Details provided in the stem of the item, such as behavioral changes or clinical changes (or both) within a certain time period, can provide a clue to the most appropriate response or (in some cases) responses. During pregnancy, alcohol withdrawal may be treated using: 1 .disulfiram (Antabuse). 2 .corticosteroids. 3 .benzodiazepines. 4 .aminophylline. - ✔✔ 3 Symptoms that occur during alcohol withdrawal can be managed with short- acting barbiturates or benzodiazepines. Disulfiram is contraindicated in pregnancy because it is teratogenic. Corticosteroids are not used to treat alcohol withdrawal. Aminophylline is not used to treat alcohol withdrawal. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Example: If you are being asked to identify a diet that is specific to a certain condition, your knowledge about that condition would help you choose the correct response (e.g., cholecystectomy = low-fat, high-protein, low-calorie diet). The prenatal medical record for a pregnant patient with diabetes states that amniotic fluid phosphatidylglycerol is greater than 3%. What does this indicate? 1 .The fetal lung maturation is normal. 2 .The mother may develop hydramnios. 3 .There is a chance of fetal macrosomia. 4.The mother is at risk for hypoglycemia - ✔✔ 1
1 .Muscle aches 2 .Hyperactivity 3 .Weight changes 4 .Fever 5 .Hypotensio - ✔✔1, 3, 4 Common symptoms, including myalgias, fatigue, weight change, and fevers, occur in nearly all women with SLE at some time during the course of the disease. Fatigue, rather than hyperactivity, is a common sign of SLE. Hypotension is not a characteristic sign of SLE. Although a diagnosis of SLE is suspected based on clinical signs and symptoms, it is confirmed by laboratory testing that demonstrates the presence of circulating autoantibodies. As with other autoimmune diseases, SLE is characterized by a series of exacerbations (flares) and remissions (Chin and Branch, 2012). When a pregnant woman with diabetes experiences hypoglycemia while hospitalized, what should the nurse have the woman do? 1 .Eat a candy bar. 2 .Eat six saltine crackers or drink 8 oz of milk. 3 .Drink 4 oz of orange juice followed by 8 oz of milk. 4 .Drink 8 oz of orange juice with 2 teaspoons of sugar added - ✔✔ 2 Crackers provide carbohydrates in the form of polysaccharides. A candy bar provides only monosaccharides. Milk is a disaccharide and orange juice is a monosaccharide. This will provide an increase in blood sugar but will not sustain to level. Orange juice and sugar will increase the blood sugar, but not provide a slow-burning carbohydrate to sustain the blood sugar. Test-Taking Tip: Being prepared reduces your stress or tension level and helps you maintain a positive attitude.
A pregnant woman with cardiac disease is informed about signs of cardiac decompensation. She should be told that the earliest sign of decompensation is most often: 1 .orthopnea. 2 .decreasing energy levels. 3 .moist frequent cough and frothy sputum. 4 .crackles (rales) at the bases of the lungs on auscultation. - ✔✔ 2 Decreasing energy level (fatigue) is an early finding of heart failure. Care must be taken to recognize it as a warning rather than a typical change of the third trimester. Cardiac decompensation is most likely to occur early in the third trimester, during childbirth, and during the first 48 hours following birth. Orthopnea, a moist, frequent cough, and crackles and rales appear later when a failing heart reduces renal perfusion and fluid accumulates in the pulmonary interstitial space, leading to pulmonary edema. Which medication is administered to a pregnant patient to treat hyperthyroidism? 1 .Isotretinoin (Accutane) 2 .Methimazole (Tapazole) 3 .Levothyroxine (Synthroid) 4 .Sodium iodide 131I (Hicon - ✔✔ 2 Methimazole (Tapazole) is administered to a pregnant patient to control symptoms of hyperthyroidism, improve weight gain, and reduce tachycardia. Isotretinoin (Accutane) is prescribed for cystic acne. It is not prescribed during pregnancy, because it is highly teratogenic. Levothyroxine (Synthroid) is used to treat hypothyroidism in pregnant patients who do not have a functioning thyroid tissue. Sodium iodide 131I (Hicon) is radioactive iodine.
4,Aspart (NovoLog) 5.Glargine (Lantus) - ✔✔2, 3, 4 Humalog and NovoLog are rapid-acting insulins and Humalin is a short- acting insulin. Novolin N is an intermediate-acting insulin and Lantus is a long-acting insulin. Diabetes in pregnancy puts the fetus at risk in several ways. Nurses should be aware that: 1 .with good control of maternal glucose levels, sudden and unexplained stillbirth is no longer a major concern. 2 .the most important cause of perinatal loss in diabetic pregnancy is congenital malformations. 3 .infants of mothers with diabetes have the same risks for respiratory distress syndrome because of the careful monitoring. 4 .at birth, the neonate of a diabetic mother is no longer at any greater risk. - ✔✔ 2 Congenital malformations account for 30% to 50% of perinatal deaths. Even with good control, sudden and unexplained stillbirth remains a major concern. Infants of diabetic mothers are at increased risk for respiratory distress syndrome. The transition to extrauterine life often is marked by hypoglycemia and other metabolic abnormalities. What does the nurse include in the plan of care of a patient with a cardiac disorder during the postpartum period? Select all that apply. 1 .Monitor oxygen saturation levels. 2 .Place the newborn at the bedside. 3 .Put the patient on a full liquid diet. 4 .Teach the patient how to breastfeed.
5 .Have the patient talk to the newborn. - ✔✔1, 2, 4, 5 The nurse monitors oxygen saturation levels in the patient to assess for adequate oxygenation. The nurse places the infant at the bedside so that the patient can touch the infant without expending energy. This also helps establish an emotional bond. The nurse assists the patient in breastfeeding by positioning the infant correctly for feeding. The nurse encourages the patient to talk to the newborn to involve the mother in the infant's care and help the patient feel vitally important. A fluid diet is not prescribed, because it does not ensure adequate nutrition for the infant. Which action does the nurse take to determine whether the carbohydrate intake is inadequate in a pregnant patient with diabetes? 1 .Monitor for urine ketones. 2 .Evaluate the nonstress test results. 3 .Determine the degree of glycosuria. 4 .Schedule a baseline fetal sonogram. - ✔✔ 1 If a patient with diabetes does not take in enough carbohydrates, the body resorts to breaking down fats for energy. The by-product of fat metabolism is ketones. Therefore the nurse monitors the urine for ketones. The amount of ketones in the urine helps detect inadequate carbohydrate intake. Nonstress tests will help assess the well-being of the fetus. Glycosuria does not accurately reflect the blood glucose levels because of a lowered renal threshold for glucose during pregnancy. The nurse obtains a baseline sonogram to assess gestational age in the first trimester. Test-Taking Tip: Relax during the last hour before an examination. Your brain needs some recovery time to function effectively.
because of an alteration in the normal resistance of the body to infection. Hypoglycemia occurs if there is an increase in the insulin levels. How does the nurse advise the patient who has given birth to an infant with microcephaly in the past and is now planning for the next child? 1 "There is a higher chance of having a preterm birth." 2 "You should be screened for phenylketonuria (PKU)." 3 "There may be a miscarriage in your second pregnancy." 4 "You must go for genetic counseling before conception." - ✔✔ 2 If a patient has given birth to an infant with microcephaly in the past, there is a possibility that the patient has phenylketonuria (PKU). PKU results from a deficiency in the enzyme phenylalanine hydrolase. Preterm birth is a possibility in pregnant women with untreated hypothyroidism. PKU affects brain development and function in the child; it does not cause miscarriage. Genetic counseling is more important for patients who have hereditary disorders, which can be passed on to the child. Test-Taking Tip: Because few things in life are absolute without exceptions, avoid selecting answers that include words such as always, never, all, every, and none. Answers containing these key words are rarely correct. Which medication is ideal for the treatment of systemic lupus erythematosus (SLE) in a pregnant patient? 1 Aspirin (Ecotrin)
Azathioprine (Imuran) 3 Prednisone (Deltasone) 4 Hydroxychloroquine (Plaquenil) - ✔✔ 4 Hydroxychloroquine (Plaquenil) reduces SLE disease activity in a pregnant patient without any adverse effects on the fetus. Aspirin (Ecotrin) is not recommended during pregnancy, because it has an increased risk for premature closure of the fetal ductus arteriosus. Azathioprine (Imuran) is discontinued before conception, because it is fetotoxic. Prednisone (Deltasone) is prescribed to treat SLE during pregnancy, but it increases the risk for bone demineralization, gestational diabetes, preeclampsia, premature rupture of membranes (PROM), and intrauterine growth restriction (IUGR). From 4% to 8% of pregnant women have asthma, making it one of the most common preexisting conditions of pregnancy. Severity of symptoms usually peaks: 1 in the first trimester. 2 between 17 to 24 weeks of gestation. 3 during the last 4 weeks of pregnancy. 4 immediately postpartum - ✔✔ 2
Normal maternal thyroxine (T4) levels 3 3% amniotic fluid phosphatidylglycerol 4 Fasting glucose levels less than 95 mg/dL - ✔✔ 2 Proper fetal brain development depends on normal maternal T4 levels early in pregnancy. Mild maternal hypothyroidism during the first trimester can cause neuropsychological damage in the infant. Hemoglobin A1c levels greater than 6 indicate long-term elevated glucose levels in the patient. A 3% amniotic fluid phosphatidylglycerol indicates proper lung maturation in the fetus. Fasting glucose levels less than 95 mg/dL indicate proper glycemic control in the pregnant patient. What instruction should the nurse give to a pregnant patient with hyperthyroidism who often gets fatigued and weak as a result of nervousness and hyperactivity? 1 "Ensure that you wear warm clothes." 2 "Perform aerobic exercises every day." 3 "Become involved in reading or a craft." 4 "Avoid going out in the cold or at night." - ✔✔ 3 The nurse advises the patient to engage in quiet activities, such as reading or crafting, to prevent fatigue and weakness. Extreme cold temperature is
prevented and warm clothing is suggested if the patient has cold intolerance because of hypothyroidism. The patient is hypersensitive to heat and gets easily fatigued; therefore aerobic exercises are not advised. What does the nurse recommend to a pregnant patient with diabetes who works long, irregular hours? 1 "Eat a snack hourly when at work." 2 "Try taking naps when you are free." 3 "Keep fruits or fruit juice available." 4 "Quit working for a while." - ✔✔ 3 If the patient has to be away from home for long hours, the nurse advises the patient to carry fruits or fruit juices. They contain simple carbohydrates that help control blood glucose levels. The nurse should not advise the patient to quit working, because it may not be feasible for the patient. Instead, the nurse should encourage the patient to follow a consistent daily schedule. Taking naps when free ensures rest, but it does not help keep glucose levels in check. Eating a snack every hour is not advised, because it may fluctuate blood glucose levels. Instead, three meals and two or three snacks are advised. What does the nurse inform a breastfeeding patient who is taking propylthiouracil (Propacil) for hyperthyroidism? 1 "The medication is likely to decrease milk production." 2
an alternative to insulin in women with GDM who require medication in addition to diet for blood glucose control. In some women gestational diabetes can be controlled with dietary modifications alone. Blood, not urine, glucose levels are monitored several times a day. Urine is tested for ketone content; results should be negative. A patient with gestational diabetes tells the nurse, "I'm extremely worried that my child will be diabetic, too." Which actions does the nurse take to alleviate the patient's anxiety? Select all that apply. 1 Evaluate the test results to assess fetal growth. 2 Listen to the feelings and concerns of the patient. 3 Provide factual information of risks to the patient. 4 Use therapeutic communication with the patient. 5 Ask the patient to share any fears with the nurse. - ✔✔2, 3, 4, 5 The nurse listens to the patient's feelings and concerns to assess for any misconception or misinformation that can be causing anxiety. The nurse provides factual information about any risks to the patient to correct any misconceptions. Using therapeutic communication will develop an open relationship that also helps promote trust. The nurse encourages the patient to share concerns with the nursing staff to promote collaboration in the care process. Evaluating test reports for fetal growth will help assess fetal well- being, although it does not help alleviate the patient's fears. Which interventions does the nurse implement to ease the labor process of a pregnant patient with heart disease? Select all that apply.
Place the patient in a side-lying position. 2 Use stirrups to facilitate an easy labor. 3 Monitor the patient's oxygen saturation. 4 Maintain a peaceful, calm environment. 5 Provide the patient with a relaxing back rub. - ✔✔1, 3, 4, 5 The nurse places the patient in a side-lying position to facilitate uterine perfusion. The nurse monitors the patient's oxygen saturation to assess for adequate oxygenation. The nurse maintains a calm environment to minimize the patient's anxiety. The nurse also provides a back massage to comfort the patient. Stirrups are not used because they may prevent compression of the popliteal veins or increase in blood volume in the chest. Which medication does the primary health care provider ask the nurse to administer to a patient during labor in a vaginal delivery, who has a history of a myocardial infarction (MI)? 1 Oxytocin 2 Diuretics 3 Anticoagulant 4 Epidural analgesia - ✔✔ 4
