A client with diabetes in the second trimester of pregnancy, notes that the usual dose of insulin to maintain blood glucose levels has been increasing over the last few weeks.
What would the nurse explain to the client about insulin during pregnancy?

Choice A rationale

While the amount of blood loss is critical for determining the severity of the hemorrhage and the need for immediate treatment, it is not the priority assessment before administering methylergonovine. The amount of blood loss determines the need for the drug, but the blood pressure determines its safety before administration. Methylergonovine is a potent vasoconstrictor and must be used cautiously in clients with elevated blood pressure to prevent hypertensive crisis or stroke.

Choice B rationale

Methylergonovine is an ergot alkaloid that acts as a potent vasoconstrictor and uterine stimulant. Its primary side effect and contraindication are hypertension and preeclampsia. Because the drug dramatically increases systemic vascular resistance, it can cause a sudden, severe elevation in blood pressure. Therefore, checking the blood pressure is the priority assessment to ensure the client's pressure is within safe limits before administration, preventing potential complications like stroke.

Choice C rationale

Although a change in the level of consciousness (LOC) could indicate hypovolemic shock from severe blood loss or a hypertensive emergency, it is a secondary finding. The primary, direct, and modifiable risk associated with methylergonovine administration is its potential to cause acute, severe hypertension. Checking the client's baseline blood pressure (Choice B) is the specific, essential safety check before administering this vasoconstrictive medication.

Choice D rationale

The uterine tone or atony is the indication for the medication; the client is already diagnosed with uterine atony (flaccid uterus) causing the hemorrhage. The medication's purpose is to contract the uterus (increase tone). The priority before administration, however, is to assess the client for contraindications or serious adverse reaction risks. The potent vasoconstrictive effect on peripheral arteries makes blood pressure (Choice B) the most critical pre-administration safety assessment.

Choice A rationale

Insulin resistance is a physiological change occurring in the second and third trimesters, primarily induced by placental hormones like human placental lactogen (hPL), progesterone, and cortisol. These hormones antagonize insulin action at the cellular level, necessitating higher insulin doses to maintain euglycemia. The normal fasting blood glucose is <95 mg/dL and 1-hour postprandial is ≤ 140 mg/dL.

Choice B rationale

The fetus produces its own insulin by approximately 10 weeks gestation and is not dependent on maternal insulin to regulate its blood glucose. Maternal insulin does not cross the placenta due to its large size. Glucose, however, does cross, and maternal hyperglycemia causes fetal hyperinsulinemia and subsequent fetal macrosomia.

Choice C rationale

While circulating blood volume significantly increases (by 30-50%) during pregnancy, leading to some hemodilution, this is not the primary mechanism for increased insulin requirements. The main mechanism is the anti-insulin effect of the aforementioned placental hormones that induce peripheral insulin resistance.

Choice D rationale

While dietary intake and carbohydrate metabolism shift during pregnancy, the major underlying cause for the escalating insulin need is the hormonally mediated increased insulin resistance. Nutritional adjustments are made, but they do not independently cause the progressive need for doubling or tripling of the usual pre-pregnancy insulin dose.