Gestational Diabetes

Gestational Diabetes The client is a multigravida at 28 weeks gestation, who presents to the obstetrician's ofÏce for a routine prenatal visit. She has been receiving prenatal care since 8 weeks gestation. Obstetrical History The nurse reviews the client's prenatal record prior to performing a focused nursing assessment. The client has given birth three times; once at 35 weeks (twins), once at 38 weeks (singleton) and once at 41 weeks (singleton). All of these children are alive and well. She had one spontaneous abortion at 10 weeks gestation. Question 1 of 24 How should the nurse record the client's obstetrical history using the G-T-P-A-L designation? 3-2-0-1-3. This does not reflect the client's obstetrical history. This client's GTPAL is 5 (pregnancies counting current one) - 2 (infants born at 38 and 41 weeks) - 1 (twins born at 35 weeks) - 1 (spontaneous abortion at 10 weeks) - 4 (each twin and the 2 singletons, all living). 4-1-1-1-2. This does not reflect the client's obstetrical history. This client's GTPAL is 5 (pregnancies counting current one) - 2 (infants born at 38 and 41 weeks) - 1 (twins born at 35 weeks) - 1 (spontaneous abortion at 10 weeks) - 4 (each twin and the 2 singletons, all living). 5-2-1-1-4. 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. This client's GTPAL is 5 (pregnancies counting current one) - 2 (infants born at 38 and 41 weeks) - 1 (twins born at 35 weeks) - 1 (spontaneous abortion at 10 weeks) - 4 (each twin and the 2 singletons, all living). Lowdermilk, D., Perry, S., Cashion, K., Alden, K., Olshansky, E. (2020). Maternity & Women’s Healthcare. (12th edition). St. Louis, Missouri. Pg. 378, 607. 4-2-1-0-2. This does not reflect the client's obstetrical history. This client's GTPAL is 5 (pregnancies counting current one) - 2 (infants born at 38 and 41 weeks) - 1 (twins born at 35 weeks) - 1 (spontaneous abortion at 10 weeks) - 4 (each twin and the 2 singletons, all living). The nurse notes that the client's fasting one-hour glucose screening levelfrom last week is 164 mg/dL. Question 2 of 24 Which information does the nurse recognize in the client's history to support a diagnosis of gestational diabetes? Maternal great-aunt has non-insulin dependent (Type 2) diabetes. Family history of diabetes is not considered a risk factor unless it is a first-degree relative. Child weighed 9 lbs (4.08 kg) at 41 weeks' gestation (macrosomia - birth weight greater than 4 kg). Birth of an infant weighing more than 9 lbs (4.08 kg) 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. Lowdermilk, D., Perry, S., Cashion, K., Alden, K., Olshansky, E. (2020). Maternity & Women’s Healthcare. (12th edition). St. Louis, Missouri. Pg. 492, 626, 766. Trace of protein noted in urine specimen at last prenatal visit. A trace of protein is normal during pregnancy and does not indicate that the client is at risk for gestational diabetes. Client is 64 in (1.63 m) tall and weighed 134 lbs (60.78 kgs) prior to pregnancy. This falls within the normal category for Body Mass Index (BMI) and does not constitute a risk for gestational diabetes. Further Glucose Screening The client 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. The client asks if there are any special instructions for the test in addition to fasting for 8 hours immediately prior to the test. Question 3 of 24 Which instruction should the nurse give the client? Only coffee or tea is allowed once the fasting level has been drawn. The 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. Follow an unrestricted diet and exercise pattern for at least 3 days before the test. When the client follows 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. Pagana, K., Pagana, T., Pagana T.N. (2019). Mosby's Diagnostic and Laboratory Test Reference.(14th edition). St Louis, Missouri. Elsevier. Pg. 467. Write down questions and call the laboratory for instructions the day before the test. The nurse should give pre-test instructions and answer any questions the client might have. Smoking in moderation is allowed up until the time the test begins. Smoking 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. The client asks the nurse why she wasn't tested for gestational diabetes until she was at almost 28 weeks gestation. Question 4 of 24 The nurse's response should be based on the understanding of which normal physiologic change of pregnancy? Maternal insulin crosses the placenta to regulate fetal glucose levels throughout pregnancy. Maternal glucose, not insulin, crosses the placenta through the process of carriermediated facilitated diffusion. In the first trimester, estrogen and progesterone cause an increase in maternal fasting glucose levels. Increasing levels of estrogen and progesterone in the first trimester stimulate the pancreas to increase insulin production, resulting in decreased blood glucose levels. Hormonal changes in the second and third trimesters result in increased maternal insulin resistance. 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. Lowdermilk, D., Perry, S., Cashion, K., Alden, K., Olshansky, E. (2020). Maternity & Women’s Healthcare. (12th edition). St. Louis, Missouri. Pg. 726. Fetal insulin production increases each trimester, forcing the mother's body to produce more glucose. Fetal 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. Submit Previous Section Section 3 Interdisciplinary Client Care The client's 3-hour oral glucose tolerance test indicates that she does have gestational diabetes. The nurse phones her and arranges for her to meet with the obstetrician, as well as a diabetes educator and a registered dietician (RD) the next day. The obstetrician and the nurse discuss gestational diabetes with the client. After seeking her input, they outline their suggested plan of care, which includes dietary control and glucose self-monitoring. After the obstetrician leaves, the client appears confused and asks the nurse, "How will I know if I have high blood sugar?" Question 5 of 24 Which response should the nurse give to the client? (Select all that apply. One, some, or all options may be correct.) Select all that apply "Hyperglycemia often presents as increased thirst and urination." This is accurate. Hyperglycemia manifestations include increased thirst and increased urination. Lowdermilk, D., Perry, S., Cashion, K., Alden, K., Olshansky, E. (2020). Maternity & Women’s Healthcare. (12th edition). St. Louis, Missouri. Pg. 619. "Hyperglycemia causes a headache and flushed, dry skin." This is accurate. Hyperglycemia symptoms include headache and flushed, dry skin. Lowdermilk, D., Perry, S., Cashion, K., Alden, K., Olshansky, E. (2020). Maternity & Women’s Healthcare. (12th edition). St. Louis, Missouri. Pg. 619. "Hyperglycemia causes cool and clammy skin." Hypoglycemia, not hyperglycemia, causes cool and clammy skin. "Hyperglycemia causes an increased sensation of being hungry." Hypoglycemia, not hyperglycemia, presents as increased hunger. After all of her questions are answered, the client is scheduled for a return visit with the obstetrician in 1 week, and she is escorted to the ofÏce of the Registered Dietician (RD). The RD discusses the need to control carbohydrates while maintaining an appropriate carbohydrateprotein-fat ratio to promote consistent weight gain (based on the client's body mass index), prevent ketoacidosis, and encourage normoglycemia (euglycemia). The client is then introduced to the diabetes educator. She asks the nurse to clarify what the RD told her about the content and timing of her meals. Question 6 of 24 Which responses should the nurse give to the client? (Select all that apply. One, some, or all options may be correct.) Select all that apply Eliminate the bedtime snack if heartburn develops after eating. A substantial bedtime snack is necessary to prevent hypoglycemia during the night. Choose complex carbohydrates that are high in fiber content. 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. Lowdermilk, D., Perry, S., Cashion, K., Alden, K., Olshansky, E. (2020). Maternity & Women’s Healthcare. (12th edition). St. Louis, Missouri. Pg. 617-620. Increase the percentage of protein in the diet if anemia develops. Although 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. Avoid foods high in refined sugars. Foods with refined sugars should be avoided to prevent hyperglycemia. Lowdermilk, D., Perry, S., Cashion, K., Alden, K., Olshansky, E. (2020). Maternity & Women’s Healthcare. (12th edition). St. Louis, Missouri. Pg. 617-620. Drink between 8 to 10 cups of fluids daily. Pregnant women should drink between 8 and 10 cups of fluid every day. Most of this fluid should be water, with avoidance of drinks devoid of nutrients, such as carbonated beverages. The diabetes educator makes a plan of care to teach the client to monitor her glucose levels. The diabetes educator discusses the use of self-glucose monitoring and gives the client verbal and written guidance about optimal glucose levels at each glucose testing point throughout the day. The nurse also provides instructions about calibration of the glucose monitor, fingerstick technique, and use of the monitor for testing. After a review of the instructions and a successful return demonstration by the client, they agree to meet after the client's prenatal appointment to follow up on the teaching/learning.GClick for Image Question 7 of 24 Which instructions should the diabetes educator include regarding when to perform fingerstick blood glucose (FSBG) monitoring? Check fasting blood sugar at lunch time. A fasting blood sugar will be done first thing in the morning before breakfast. Perform blood glucose monitoring prior to breakfast (fasting) and before 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. Lowdermilk, D., Perry, S., Cashion, K., Alden, K., Olshansky, E. (2020). Maternity & Women’s Healthcare. (12th edition). St. Louis, Missouri. Pg. 630. Peform blood glucose monitoring two hours after all meals, at bedtime, and in the middle of the night. This is the protocol for FSBG testing for the client 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. Perform blood glucose monitoring once a day at dinner time. This pattern of FSBG testing does not accurately identify if the prescribed diet is promoting euglycemia, especially at the onset of treatment. Section 4 A Complication Occurs The client manages her gestational diabetes with diet. She experiences a few episodes of postprandial hyperglycemia but does not have to take insulin. At her 36-week prenatal visit, the obstetrician assesses the client and finds that there is no increase in fetal growth since the previous week. When questioned further, she tells the obstetrician that the fetus seems to have slowed down a little the last few days. The client is scheduled for a biophysical profile (BPP) and is admitted to the hospital's antepartum unit. The antepartum nurse performs a nonstress test (NST) as part of the BPP. Question 8 of 24 Which fetal heart rate (FHR) changes indicate a reactive nonstress test? Persistent late decelerations associated with three uterine contractions, lasting 40 to 60 seconds each in a 10-minute period. This describes a positive contraction stress test. An increase in the FHR baseline to 170 beats per minute, lasting for at least 20 minutes. This describes fetal tachycardia. Marked FHR variability in response to contractions caused by nipple stimulation. This is often seen as a response to uterine hyperstimulation or mild fetal hypoxemia, but it is not part of the nonstress test. Two episodes of acceleration (greater than 15 beats/minute, lasting more than 15 seconds) related to fetal movement in a 20-minute period. This describes a reactive nonstress 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 to 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. Lowdermilk, D., Perry, S., Cashion, K., Alden, K., Olshansky, E. (2020). Maternity & Women’s Healthcare. (12th edition). St. Louis, Missouri. Pg. 578. The client has a nonreactive nonstress 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, Nonreactive Nonstress Test = 0, and Qualitative Amniotic Fluid Volume = 2). On the basis of this score, the obstetrician recommends that an amniocentesis be completed to assess for fetal lung maturity before a decision is made whether to induce delivery for the client the following day.GClick for Image Question 9 of 24 Prior to the amniocentesis, which action should the nurse take first? Administer Rh immune globulin if client is Rh negative. This will be done after the amniocentesis. 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 amniocentesis is done for genetic studies. Pagana, K., Pagana, T., Pagana T.N. (2019). Mosby's Diagnostic and Laboratory Test Reference.(14th edition). St Louis, Missouri. Elsevier. Pg. 52. Apply the external fetal monitor to evaluate uterine contractility. This will be done immediately after the procedure to assess for uterine irritability. Fetal heart rate will also be assessed using external monitoring. Clean the abdomen with betadine solution and sterile 4 by 4s. Another action must be done prior to prepping the abdomen for the procedure. he client 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., she complains of increased uterine discomfort and is contracting every 10 minutes. While the antepartum nurse is in the room, the client's membranes rupture spontaneously.GClick for ImageClick for Image Question 10 of 24 Which action by the nurse takesGpriority? Notify the obstetrician of the changes in the client's status. Although this will be done, it is not the priority action. Transfer the client to the labor-delivery-recovery (LDR) suites. Reapply the external fetal monitor to evaluate the fetal heart rate. Start an intravenous line using an 18-gauge or larger intravenous catheter. Labor Medications The client is transferred to the labor-delivery-recovery (LDR) suite. The antepartum nurse gives report to the LDR nurse and the graduate nurse (GN) who is observing the delivery. A vaginal examination is done. The nurse determines that client 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 and lasting 70 seconds, and the nurse palpates the quality as strong. The fetal heart rate shows a reassuring pattern. A fingerstick blood glucose (FSBG) is also done on admission. The result is 138 so the obstetrician orders an intravenous insulin drip. The client also receives maintenance IV fluids of D5LR at 125 mL/hr. If a fluid bolus is needed, Lactated Ringer's will be used. The obstetrician orders 20 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 80 and 110 mg/dL. Question 11 of 24 Fill in the blankAt what rate should the nurse initially set the intravenous pump? (Enter numeric value only. If rounding is necessary, round to the tenth.)G 12.5 Submit The client's spouse arrives to be her labor coach and is surprised to learn that she needs IV insulin and is being so closely monitored. The spouse tells the labor nurse that the obstetrician discussed the possible need for insulin at a prenatal visit, but now the spouse is uncertain why the blood sugar is being maintained between 80 and 110 mg/dL. The client's spouse arrives to be her labor coach and is surprised to learn that she needs IV insulin and is being so closely monitored. The spouse tells the labor nurse that the obstetrician discussed the possible need for insulin at a prenatal visit, but now the spouse is uncertain why the blood sugar is being maintained between 80 and 110 mg/dL. Question 12 of 24 The nurse's response should be based on what information? More insulin will be available for fetal use via placental transfer. Maternal insulin (endogenous or exogenous) does not cross the placenta because the insulin molecule is too large. A glucose level more than 90 to 100 puts the client at risk for infection in labor. While an infection does put a woman at risk for developing ketoacidosis, a high glucose level in labor does not predispose the client to infection. An elevated glucose in labor increases the risk of 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 neonate's blood glucose level decreases rapidly in the presence of fetal hyperinsulinemia. Lowdermilk, D., Perry, S., Cashion, K., Alden, K., Olshansky, E. (2020). Maternity & Women’s Healthcare. (12th edition). St. Louis, Missouri. Pg. 630. Maintaining euglycemia in labor decreases the need for insulin postpartum. While 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, the client is 6 cm dilated. She requests pain medication to "take the edge off" the contractions, but she does not want an epidural. The nurse calls the obstetrician and receives an order for butorphanol tartrate 1 mg IV. Question 13 of 24 Two hours later, the client is 6 cm dilated. She requests pain medication to "take the edge off" the contractions, but she does not want an epidural. The nurse calls the obstetrician and receives an order for butorphanol tartrate 1 mg IV. Question 13 of 24 Which assessment information isGmostGimportant for the nurse to validate with the laboring client before giving the medication? Past or present history of opioid dependence. Butorphanol tartrate is an opioid agonist-antagonist. Respiratory depression, nausea, and vomiting occur less often with this group of drugs when compared with opioid agonists. However, because butorphanol tartrate 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 the neonate. Skidmore-Roth, L. (2021). Mosby’s 2021 Nursing Drug Reference. th (34 Gedition). St. Louis, Missouri. Elsevier. Pg. 205. Length of all previous labor experiences. Although 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. Herbal preparation use during pregnancy. Several herbs, including chamomile, kava, skullcap, hops, and valerian can increase CNS depression if used concomitantly with butorphanol tartrate . However, another assessment is more important. Previous use of analgesia or anesthesia in labor. While it is important to know what types of analgesia and anesthesia the client has used in the past, including efÏcacy and side effects, another assessment is more important. Section 6 Legal Issues The client tells the nurse that she would like to receive one-half of the prescribed dose of butorphanol tartrate because the last time she was given that medication she felt like she was floating and then experienced some confusion. Question 14 of 24 Which action should the nurse take? Administer one-half of the dose as requested. This is not within the nurse's scope of practice. Tell the client that she must take the whole dose. The client has the right to request a lower dose or refuse the medication. Request that the obstetrician change the order. The nurse should consult the obstetrician if the nurse believes an order should be altered. The nurse cannot reduce a medication dose without consulting the obstetrician, even at the client's request. Willihnganz, M., Gurevitz, S., Clayton, B. (2020). Clayton’s Basic th Pharmacology for Nurses. (18 Gedition). St. Louis, Missouri. Elsevier. Pg. 75. Substitute a medication with fewer side effects. This is not within the nurse's scope of practice. Submit The client receives the analgesic, and obtains relief. Within 30 minutes she has progressed to 8 cm dilation, she is fully effaced, and the fetus is at a 0 station. The nurse caring for her 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 the laboring client, who is entering transition, and the care of 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 the client gives birth. The charge nurse refuses, telling the nurse, "there just isn't anyone else." Section 7 The nursing supervisor speaks with the nurse and the charge nurse. The situation is resolved by having the charge nurse admit the new client while the nurse continues to help the laboring client throughout transition and birth. An on-call nurse is called to assume care of the new client. Section 8 Care During Birth The client 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 the client and her spouse and notifies the obstetrician of the client's progress. The obstetrician is at the bedside and is prepared for delivery. After three cycles of open-glottis pushing, the baby's head is crowning. The head is born easily over an intact perineum but rotates externally and retracts back against the perineum. The nurse and obstetrician recognize these signs as an indication of shoulder dystocia. Question 15 of 24 WhichGimmediateGaction should the nurse take? Notify the operating room to prepare for a cesarean section. Pushing 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. Apply external pressure to the uterine fundus. Fundal pressure further wedges the shoulder under the symphysis pubis and may cause injury to mother and fetus. Administer 0.25 mg terbutaline subcutaneously. This medication would relax the uterus, which is not needed at this time. 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 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. The nurse notes what time the head delivered and assists with the initial intervention for the shoulder dystocia. The obstetrician is still having difÏculty delivering the shoulders. Question 16 of 24 Which of the following actions should the nurse be prepared for at this time? Elevate the hips with pillows. Elevating the hips with pillows is an action used for a cord prolapse, not a shoulder dystocia. Apply fundal pressure. Fundal pressure should be avoided when intervening for a shoulder dystocia. Fundal pressure will push the anterior shoulder even more firmly against the mother’s symphysis. Position the client in Trendelenburg. Positioning a client in Trendelenburg is an action the nurse would do for a cord prolapse, not a shoulder dystocia. Apply suprapubic pressure. Suprapubic pressure pushes the fetal anterior shoulder downward to displace it from above the mother’s symphysis pubis As the nurse performs the intervention, the obstetrician cuts an episiotomy. The client pushes and the male infant is born. He weighs 9 lbs 9 oz (4.34 kgs) and has an Apgar of 7 at 1 minute, then 9 at 5 minutes, requiring only stimulation and bulb suctioning. The nurse performs a physical assessment of the newborn prior to giving him to his mother to breastfeed.GClick for Image Question 17 of 24 Which newborn behavior indicates to the nurse that the infant has suffered a complication from the shoulder dystocia? Unilateral absence of the Moro reflex. 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. Lowdermilk, D., Perry, S., Cashion, K., Alden, K., Olshansky, E. (2020). Maternity & Women’s Healthcare. (12th edition). St. Louis, Missouri. Pg. 476, 477. One eye remains open when crying. This is indicative of facial paralysis (palsy), which is not a common sequellae of shoulder dystocia. Positive Babinski reflex bilaterally. This is a normal response in the newborn. Presence of caput succedaneum. While this may occur in the infant who has shoulder dystocia, it is a common finding in the newborn and has no pathological significance. Submit The newborn's assessment is normal. The client breastfed her other children, but is concerned because she read that infants of diabetic mothers are at greater risk for jaundice than infants of nondiabetic mothers. She is also worried about the infant developing hypoglycemia. Question 18 of 24 What should the nurse recommend to the client in regard to infant feeding? The infant requires formula to prevent hypoglycemia and jaundice. There is a better feeding alternative. The newborn needs breast milk and 5% dextrose water. There is a better feeding alternative. Breastfeeding should be initiated immediately and done on demand. 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. Lowdermilk, D., Perry, S., Cashion, K., Alden, K., Olshansky, E. (2020). Maternity & Women’s Healthcare. (12th edition). St. Louis, Missouri. Pg. 510. A mixture of breastmilk and formula will prevent complications. There is a better feeding alternative. Two hours after her delivery, the labor and delivery nurse notifies the postpartum charge nurse that the client and her son will be transferred to the unit. The charge nurse is also notified that three other motherinfant couplets will be transferred at about the same time. The postpartum unit is staffed with a new graduate nurse who has completed orientation, a nurse with 3 years experience, a nurse with 10 years experience, and a PN with 20 years experience. Question 19 of 24 Which client should the charge nurse assign the PN? The client who is a gestational diabetic and had a problem breastfeeding. Since the 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. A multigravida who had an uncomplicated term delivery and is breastfeeding. Once the initial assessment is done, the PN is qualified to care for this client because there are no complications expected. Cooper, K., Gosnell, K. (2019). Foundations of Nursing. (8th edition). St. Louis, Missouri. Elsevier. Pg. 1238. A primigravida who had a cesarean delivery 4 hours ago and is bottle feeding. The new graduate who has finished with orientation is qualified to take care of this mother-infant couplet. A primigravida who is 12 hours posteclamptic seizure and is bottle feeding. The client who is postseizure requires the RN with the greatest experience to monitor the postpartum period and deal with psychosocial issues. As the charge nurse walks down the hall to tell the nurses about the new admissions, she hears one of the nurses giving misinformation about the Rh immune globulin injection to a client and her husband. Question 20 of 24 Which information should the nurse give about the Rh immune globulin injection? Rh immune globulin is given to the infant within 48 hours of delivery. Rh immune globulin is given to the postpartum mother, not the infant. Rh immune globulin is given to the mother within 72 hours of delivery, if the infant is Rh-positive. Rh immune globulin is given to a mother who has Rh-negative blood and the infant is Rh-positive. It is given within 72 hours of delivery. Lowdermilk, D., Perry, S., Cashion, K., Alden, K., Olshansky, E. (2020). Maternity & Women’s Healthcare. (12th edition). St. Louis, Missouri. Pg. 433. Rh immune globulin is a vaccine given to a mother with Rh-positive blood within 24 hours of delivery. Rh immune globulin is an Rh immune globulin given to a woman with Rhnegative blood. Rh immune globulin is given at 18 weeks gestation to mothers with Rhnegative blood. Rh immune globulin is given at 28 weeks' gestation in women with Rhnegative blood. 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 the client ambulated to the bathroom without difÏculty and voided just prior to being transferred. An initial assessment is completed by the postpartum nurse. Question 21 of 24 Where will the nurse expect to palpate the uterine fundus? Midline at the umbilicus. 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. Lowdermilk, D., Perry, S., Cashion, K., Alden, K., Olshansky, E. (2020). Maternity & Women’s Healthcare. (12th edition). St. Louis, Missouri. Pg. 425. Midline 2 cm above the umbilicus. This is not the expected position of the fundus at 2 hours post birth. Shifted left at the umbilicus. This is not the expected position of the fundus at 2 hours post birth. Shifted right 4 cm below umbilicus. This is not the expected position of the fundus at 2 hours post birth. The client asks the nurse why the insulin was discontinued after the baby was born and asks if she will have to take a shot or a pill now. Question 22 of 24 The nurse's response should be based on which information? Most women with gestational diabetes return to normal glucose levels after birth. 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. Lowdermilk, D., Perry, S., Cashion, K., Alden, K., Olshansky, E. (2020). Maternity & Women’s Healthcare. (12th edition). St. Louis, Missouri. Pg. 630. Sliding scale insulin will be needed for 6 weeks postpartum. This does not describe the normal postpartum course for the woman with gestational diabetes. Breastfeeding increases the need for insulin so an insulin pump will be applied. This does not describe the normal postpartum course for the woman with gestational diabetes. Oral hypoglycemics will be started as soon as the client is eating a regular diet. This does not describe the normal postpartum course for the woman with gestational diabetes. Submit Two days later, the client and her infant are both stable and breastfeeding is well established. The nurse is preparing discharge teaching and notes that the client 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. Question 23 of 24 What should be the nurse's next action? Care for both of the clients. This increases the risk of compromised care for both clients. Call the clients' healthcare provider. The nurse should take another action first. Contact the nursing supervisor. This is appropriate use of what is known as the chain of command. If a nurse 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. Nguyen, J., & McTeigue, J. (2019). Legal and Ethical Issues for Health Professions (4th ed.). St. Louis, MO: Elsevier. p. 43. Refuse to care for either client. This could constitute client abandonment. Submit Question 24 of 24 Which information is most important for the nurse to discuss concerning the use of contraception while breast feeding? (Select all that apply. One, some, or all options may be correct.) Select all that apply Irregular vaginal bleeding (breakthrough bleeding) is not unusual when using this medication and usually lessens over time. Although this is true, it is not the most important information for the nurse to discuss. If a dose is taken more than 3 hours late, a backup method of birth control must be used for the next 48 hours. Because this medication contains such a low dose of progestin, it should be taken at exactly the same time every day; if this is not done, the risk of pregnancy increases at a much greater rate than if one misses a combined estrogen-progestin pill. Lowdermilk, D., Perry, S., Cashion, K., Alden, K., Olshansky, E. (2020). Maternity & Women’s Healthcare. (12th edition). St. Louis, Missouri. Pg. 437. Willihnganz, M., Gurevitz, S., Clayton, B. (2020). Clayton’s Basic Pharmacology for th Nurses. (18 edition). St. Louis, Missouri. Elsevier. Pg. 283, 320, 621. It is important to notify laboratory personnel that this medication is being used because it alters the results of certain tests. Although this is true, it is not the most important information for the nurse to discuss. It is important to use another method of contraception prior to starting the Mini Pill. Breastfeeding can suppress fertility, but it is important to understand that as soon as there is a decline in breastfeeding, the contraceptive protection decreases and other nonpharmacological methods should be considered. Lowdermilk, D., Perry, S., Cashion, K., Alden, K., Olshansky, E. (2020). Maternity & Women’s Healthcare. (12th edition). St. Louis, Missouri. Pg. 437. Willihnganz, M., Gurevitz, S., Clayton, B. (2020). Clayton’s Basic Pharmacology for th Nurses. (18 edition). St. Louis, Missouri. Elsevier. Pg. 283, 320, 621. The medication may be taken with food if the side effect of nausea occurs when ingested on an empty stomach Although this is true, it is not the most important information for the nurse to discuss. Submit Previous Section