HESI CASE STUDY_Gestational Diabetes
Content
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.
INCORRECT
This does not reflect the client's obstetrical history.
B) 3-1-1-1-2.
INCORRECT
This does not reflect the client's obstetrical history.
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).
D) 4-2-1-0-2.
INCORRECT
This 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.
INCORRECT
Family 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.
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.
C) Trace of protein noted in urine specimen at last prenatal visit.
INCORRECT
A 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.
INCORRECT
This 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.
INCORRECT
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.
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) Write down questions and call the laboratory for instructions the day before the test.
INCORRECT
The 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.
INCORRECT
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.
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.
INCORRECT
Maternal 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.
INCORRECT
Increasing 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.
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.
D) Fetal insulin production increases each trimester, forcing the mother's body to produce more
glucose.
INCORRECT
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.
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."
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 bottlefeeding, or after breastfeeding has been stopped, and repeated at regular intervals as part of wellwoman 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."
INCORRECT
This 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."
INCORRECT
The RN should answer Amanda's question.
D) "Tell me what worries you about the possibility of developing Type 2 diabetes after your
pregnancy ends."
INCORRECT
While 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.
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.
C) Increase the percentage of protein in the diet if anemia develops.
INCORRECT
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.
D) Vary timing of meals and snacks based on individual preferences.
INCORRECT
While 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.
INCORRECT
This 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.
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.
C) Before and 2 hours after all meals, at bedtime, and during the night.
INCORRECT
This 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.
INCORRECT
This 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.
INCORRECT
This describes a positive contraction stress test.
B) An increase in the FHR baseline to 170 beats per minute, lasting for at least 20 minutes.
INCORRECT
This describes fetal tachycardia.
C) Marked FHR variability in response to contractions caused by nipple stimulation.
INCORRECT
This 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.
INCORRECT
This will be done after the amniocentesis.
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) Apply the external fetal monitor to evaluate uterine contractility.
INCORRECT
This 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.
INCORRECT
Another 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.
INCORRECT
Although this will be done, it is not the priority action.
B) Transfer Amanda to the labor-delivery-recovery (LDR) suites.
INCORRECT
Although this will be done, it is not the priority action.
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.
D) Start an intravenous line using an 18 gauge or larger intravenous catheter.
INCORRECT
Although 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.
INCORRECT
Please recalculate.
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) 25 ml/hr.
INCORRECT
Please recalculate.
D) 100 ml/hr.
INCORRECT
Please 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.
INCORRECT
Maternal 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.
INCORRECT
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.
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.
D) Maintaining euglycemia in labor decreases the need for insulin postpartum.
INCORRECT
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, 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.
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.
B) Length of all previous labor experiences.
INCORRECT
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.
C) Herbal preparation use during pregnancy.
INCORRECT
Several 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.
INCORRECT
While 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.
INCORRECT
This is not within the RN's scope of practice.
B) Tell the client that she must take the whole dose.
INCORRECT
The client has the right to request a lower dose or refuse the medication.
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.
D) Substitute a medication with fewer side effects.
INCORRECT
This 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.
INCORRECT
This increases the risk of compromised care for both clients.
B) Call the clients' healthcare provider.
INCORRECT
The nurse should take another action first.
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) Refuse to care for either client.
INCORRECT
This 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.
INCORRECT
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.
B) Apply external pressure to the uterine fundus.
INCORRECT
Fundal 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.
INCORRECT
This medication would relax the uterus, which is not needed at this time.
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.
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.
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.
B) One eye remains open when crying.
INCORRECT
This is indicative of facial paralysis (palsy), which is not a common sequellae of shoulder
dystocia.
C) Positive Babinski reflex bilaterally.
INCORRECT
This is a normal response in the newborn.
D) Presence of caput succedaneum.
INCORRECT
While 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.
INCORRECT
There is a better feeding alternative.
B) The newborn needs breast milk and 5% dextrose water.
INCORRECT
There is a better feeding alternative.
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.
D) A mixture of breastmilk and formula will prevent complications.
INCORRECT
There 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.
INCORRECT
Since 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.
CORRECT
Once 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.
INCORRECT
The 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.
INCORRECT
This 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.
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.
C) Ask the education department to schedule an inservice on Rubella vaccine.
INCORRECT
While 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.
INCORRECT
An 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.
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.
B) Midline 2 cm above the umbilicus.
INCORRECT
This is not the expected position of the fundus at 2 hours post birth.
C) Shifted left at the umbilicus.
INCORRECT
This is not the expected position of the fundus at 2 hours post birth.
D) Shifted right 4 cm below umbilicus.
INCORRECT
This 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.
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.
B) Sliding scale insulin will be needed for 6 weeks postpartum.
INCORRECT
This 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.
INCORRECT
This 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.
INCORRECT
This 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 Progestinonly 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.
INCORRECT
Although 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.
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.
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.
INCORRECT
This does not reflect the client's obstetrical history.
B) 3-1-1-1-2.
INCORRECT
This does not reflect the client's obstetrical history.
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).
D) 4-2-1-0-2.
INCORRECT
This 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.
INCORRECT
Family 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.
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.
C) Trace of protein noted in urine specimen at last prenatal visit.
INCORRECT
A 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.
INCORRECT
This 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.
INCORRECT
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.
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) Write down questions and call the laboratory for instructions the day before the test.
INCORRECT
The 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.
INCORRECT
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.
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.
INCORRECT
Maternal 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.
INCORRECT
Increasing 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.
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.
D) Fetal insulin production increases each trimester, forcing the mother's body to produce more
glucose.
INCORRECT
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.
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."
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 bottlefeeding, or after breastfeeding has been stopped, and repeated at regular intervals as part of wellwoman 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."
INCORRECT
This 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."
INCORRECT
The RN should answer Amanda's question.
D) "Tell me what worries you about the possibility of developing Type 2 diabetes after your
pregnancy ends."
INCORRECT
While 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.
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.
C) Increase the percentage of protein in the diet if anemia develops.
INCORRECT
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.
D) Vary timing of meals and snacks based on individual preferences.
INCORRECT
While 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.
INCORRECT
This 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.
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.
C) Before and 2 hours after all meals, at bedtime, and during the night.
INCORRECT
This 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.
INCORRECT
This 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.
INCORRECT
This describes a positive contraction stress test.
B) An increase in the FHR baseline to 170 beats per minute, lasting for at least 20 minutes.
INCORRECT
This describes fetal tachycardia.
C) Marked FHR variability in response to contractions caused by nipple stimulation.
INCORRECT
This 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.
INCORRECT
This will be done after the amniocentesis.
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) Apply the external fetal monitor to evaluate uterine contractility.
INCORRECT
This 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.
INCORRECT
Another 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.
INCORRECT
Although this will be done, it is not the priority action.
B) Transfer Amanda to the labor-delivery-recovery (LDR) suites.
INCORRECT
Although this will be done, it is not the priority action.
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.
D) Start an intravenous line using an 18 gauge or larger intravenous catheter.
INCORRECT
Although 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.
INCORRECT
Please recalculate.
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) 25 ml/hr.
INCORRECT
Please recalculate.
D) 100 ml/hr.
INCORRECT
Please 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.
INCORRECT
Maternal 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.
INCORRECT
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.
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.
D) Maintaining euglycemia in labor decreases the need for insulin postpartum.
INCORRECT
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, 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.
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.
B) Length of all previous labor experiences.
INCORRECT
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.
C) Herbal preparation use during pregnancy.
INCORRECT
Several 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.
INCORRECT
While 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.
INCORRECT
This is not within the RN's scope of practice.
B) Tell the client that she must take the whole dose.
INCORRECT
The client has the right to request a lower dose or refuse the medication.
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.
D) Substitute a medication with fewer side effects.
INCORRECT
This 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.
INCORRECT
This increases the risk of compromised care for both clients.
B) Call the clients' healthcare provider.
INCORRECT
The nurse should take another action first.
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) Refuse to care for either client.
INCORRECT
This 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.
INCORRECT
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.
B) Apply external pressure to the uterine fundus.
INCORRECT
Fundal 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.
INCORRECT
This medication would relax the uterus, which is not needed at this time.
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.
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.
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.
B) One eye remains open when crying.
INCORRECT
This is indicative of facial paralysis (palsy), which is not a common sequellae of shoulder
dystocia.
C) Positive Babinski reflex bilaterally.
INCORRECT
This is a normal response in the newborn.
D) Presence of caput succedaneum.
INCORRECT
While 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.
INCORRECT
There is a better feeding alternative.
B) The newborn needs breast milk and 5% dextrose water.
INCORRECT
There is a better feeding alternative.
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.
D) A mixture of breastmilk and formula will prevent complications.
INCORRECT
There 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.
INCORRECT
Since 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.
CORRECT
Once 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.
INCORRECT
The 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.
INCORRECT
This 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.
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.
C) Ask the education department to schedule an inservice on Rubella vaccine.
INCORRECT
While 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.
INCORRECT
An 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.
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.
B) Midline 2 cm above the umbilicus.
INCORRECT
This is not the expected position of the fundus at 2 hours post birth.
C) Shifted left at the umbilicus.
INCORRECT
This is not the expected position of the fundus at 2 hours post birth.
D) Shifted right 4 cm below umbilicus.
INCORRECT
This 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.
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.
B) Sliding scale insulin will be needed for 6 weeks postpartum.
INCORRECT
This 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.
INCORRECT
This 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.
INCORRECT
This 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 Progestinonly 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.
INCORRECT
Although 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.
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.
