GDM ob

1.
How should the nurse record Amanda’s obstetrical history using the G-T-P-A-L designation?

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?

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?

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?

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?

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?

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 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?

.

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?

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?

C) Reapply the external fetal monitor to evaluate the fetal heart rate.
CORRECT
The 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.

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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.

C) 4-1-1-1-3.
CORRECT
Gravidity [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).

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

B) Follow an unrestricted diet and exercise pattern for at least 3 days before the test.
CORRECT
By 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) Hormonal changes in the second and third trimesters result in increased maternal insulin resistance.
CORRECT
Increased 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.

A) “You will need to be periodically evaluated for Type 2 diabetes for the rest of your life.”
CORRECT
The 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) Choose complex carbohydrates that are high in fiber content.
CORRECT
The 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.

E) Drink 8-10 cups of fluid daily

B) Prior to breakfast (fasting) and 2 hours after each meal.
CORRECT
This 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.

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

B) Assist the client to the bathroom and ask her to empty her bladder.
CORRECT
In 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) Reapply the external fetal monitor to evaluate the fetal heart rate.
CORRECT
The 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.

B) 10 ml/hr.
CORRECT
Ratio and proportion method:
25 u/250 ml = 1 u/X ml
Cross-multiply: 25X = 250
Therefore, X = 250/25 = 10 ml/hour

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

C) An elevated glucose in labor increases the risk of neonatal hypoglycemia.
CORRECT
Maternal 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.

A) Past or present history of opioid dependence.
CORRECT
Stadol 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.

C) Request that the provider change the prescription.
CORRECT
The 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.

C) Contact the nursing supervisor.
CORRECT
This 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) Reposition the client using McRobert’s maneuver.
CORRECT
The 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.

A) Unilateral absence of the Moro reflex.
CORRECT
This 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.

C) Breastfeeding should be initiated immediately and done on demand.
CORRECT
Breastfeeding 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.

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

B) Speak to the nurse in the hall so the nurse can correct the information for the client.
CORRECT
The 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.

A) Midline at the umbilicus.
CORRECT
The 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.

A) Most women with gestational diabetes return to normal glucose levels after birth.
CORRECT
Because 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.

23.
Which information is most important for the nurse to discuss concerning the use of this medication?
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.
CORRECT
Because 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.
D) It is important to use another method of contraception prior to starting the Mini pill.
CORRECT
Breastfeeding can suppress fertility, as it declines, contraceptive protection decreases and other pharmacological methods should be considered.
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