HESI Gestational Diabetes- Amanda Garrison
The patient has given birth twice, once at 35 weeks (twins) and once at 39 weeks (singleton). All of these children are alive. She had one spontaneous abortion at 9 weeks’ gestation. How would you record the GTPAL?
4-1-1-1-3. Gravidity is defined as the number of times pregnant, including the current pregnancy. Term is defined as any birth after the end of the 37th week, and preterm refers to any births between 20 and 37 weeks. Both term and preterm describe liveborn and stillborn infants. Abortion is any fetal loss, whether spontaneous or elective, up to 20 weeks gestation. Living refers to all children who are living at the time of the interview. Multiple fetuses are treated as one pregnancy and one birth; each are counted as living.
The nurse recognizes that what information in the client’s history supports a diagnosis of gestational diabetes?
Youngest child weighed 4300g at 39 weeks’ gestation. Birth of an infant weighing more than 9lb is a RF for gestational diabetes.
The patient is scheduled for a 3-hour oral glucose tolerance test in 5 days and is told to arrive at the lab at 8:30am. Which instruction should the nurse give?
Follow an unrestricted diet and exercise pattern for at least 3 days before the test. When the client follows an unrestricted diet and exercise pattern the test is a true determination of the body’s ability to handle the glucose load given after the FBG is drawn.
The patient asks why she wasn’t tested for GDM until she was at almost 28 weeks gestation. The Nurse’s response should be based on the understanding of which normal physiologic change?
Hormonal changes in the second and third trimesters result in increased maternal insulin resistance. Increased levels of hormones increase insulin resistance b/c they act as insulin antagonists. This serves as a glucose-sparing mechanism to ensure an adequate glucose supply to the fetus.
The patient newly diagnosed w/GDM asks, “Does this mean I will always have diabetes?” Which response should the nurse give the client?
You will need to be periodically evaluated for Type 2 DM for the rest of your life. The pt w/GDM is at increased risk for developing T2DM later in life. Crab intolerance should be evaluated 6-12mos after pregnancy (if bottle-feeding), or after BF has stopped.
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The RD discusses the need to control crabs while maintaining appropriate crab-proto-fat ratio to promote consistent weight gain, prevent ketoacidosis, and encourage normoglycemia. The pt asks the RN to clarify what the RD said. Which response(s) should the use give the client (SATA):
Choose complex crabs that are high in fiber, drink 8-10 cups of fluids daily.
Which fingerstick blood glucose testing protocol should the diabetes educator recommend for the patient?
Prior to breakfast (fasting) and 2h after each meal. 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.
The antepartum RN performs an NST as part of the BPP. The nurse recognizes which FHR changes indicate a reactive NST?
Two episodes of acceleration (>15bpm, lasting >15secs) related to fetal movement in a 20m period.
An amniocentesis is recommended. Prior to the amino, which action should the nurse take first?
Assist the client to the bathroom and ask her to empty her bladder. 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 amino is done for genetic studies.
The patient experiences SROM. What action by the nurse takes priority?
Reapply the external fetal monitor to evaluate the FHR. The response of the fetus to the SROM should be evaluated immediately d/t the risk of cord prolapse. The nurse will also assess and document the color, amount, viscosity, and odor of the amniotic fluid.
The perinatologist prescribes 25 units of regular human insulin in 250mL of normal saline started at 1 unit/h with hourly dose situation to maintain FSBG between 70-90mg/dL. At what rate should the nurse initially set the intravenous pump?
10mL/h. Dimensional Analysis: 25u x 1u/1hr = 10 u/h
The patients husband arrives and is uncertain why the blood sugar is being maintained between 70-90mg/dL. The nurse’s response should be based on what information.
An elevated glucose in labor increases the risk for neonatal hypoglycemia. 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 neonates’s blood glucose level decreases rapidly in the presence of fetal hyperinsulinemia.
The nurse receives a prescription for butorphanol tartrate (stadol) 1mgIV. What assessment info is most important for the nurse to validate with the laboring client before giving the medication?
Past or present hx of opioid dependence. 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 in both mom and baby.
The patient request one-half of the prescribed dose of Stadol because of previous side effects experienced. What should the nurse do?
Request that the provider change the prescription. The nurse should consult the healthcare provider if prescription should be altered.
Amanda receives the analgesic and relief is obtained. W/in 30 mins she has progressed to 8 cm dilation and is fully effaced, and the fetus is at 0 station. The nurse asks the charge nurse to assign someone else to new client until Amanda gives birth. The CN refuses, telling the nurse that there just isn’t anyone else. What should the nurse do next?
Contact the nursing supervisor. This is appropriate use of what is know as the “chain of command.”
Amanda quickly dilates to 10 cm and feels a strong urge to push. FHR continues to be reassuring w/a baseline 145 and moderate variability present. The head is born easily over an intact perineum but rotates externally and retracts back against the perineum. The nurse and perinatologist recognize these signs as an indication of shoulder dystocia. What should the nurse do immediately?
Reposition the client using McRobert’s maneuver. The nurse should assist the woman in flexing and abducting the maternal hips, positioning the maternal thighs up onto the maternal abdomen. This is often combined with suprapubic pressure, which also helps free the shoulder from under he symphysis pubis.
The nurse should recognize that which newborn behaviors indicates that the infant has suffered a complication from the shoulder dystocia?
Unilateral absence of the Moro reflex. Indicative of a fractured clavicles, a common complication of shoulder dystocia.
What should the nurse recommend to Amanda in regard to infant feeding?
Breastfeeding should be initiated and done on demand. Breastfeeding that commences earl and is done on demand helps decrease the risk of hypoglycemia and jaundice,
Which client should the CN assign the LPN w/ 20 years’ experience?
A multigravida who had an uncomplicated term delivery and is breastfeeding. Once initial assessment is done, the LPN is qualified to care for the client b/c there are no complications expected.
What action should the CN take when she hears one of the nurses giving misinformation about the Rubella vaccine to a client and her husband?
Speak to the nurse in the hall so the nurse can correct the info for the client. This avoids embarrassing the nurse and lets the nurse preserve the relationship w/the client and her husband as well as correct misinformation.
Where will the nurse expect to palpate the uterine fundus if Amanda ambulated to the bathroom w/o difficulty and voided just prior to being transferred?
Midline at the umbilicus. The uterine fundus should be midline at the umbilicus after birth for 24 hours.
The nurse’s response should be based on which info?
Most women w/ GD return to normal glucose levels after birth. b/c the major source of insulin resistance, the placenta, is gone after birth.
Which info is most important for the nurse to discuss concerning the use of contraception while breast feeding? (SATA)
If a dose is taken more than 3 hours late, a backup method of BC must be used for the next 48 hours; It is important to use another method of contraception prior to starting the Mini Pill.