A nurse is reinforcing teaching for a newly licensed nurse about interventions for gestational diabetes mellitus (GDM). Which of the following statements by the new nurse indicates the reinforced teaching was effective?
"Clients who have GDM with unstable blood glucose control will require oral hypoglycemic agents.”.
"Clients who have GDM should test glucose levels 1 to 2 times per day.”.
"Clients who have GDM should have their hemoglobin A1C levels monitored every 1 to 2 months.”.
"Insulin dosage will be decreased during the second and third trimester in response to human placental lactogen (hPL) secretion.”.
The Correct Answer is A
Choice A rationale
Gestational diabetes mellitus is often managed with diet and exercise initially, but when glycemic targets are not met, pharmacologic therapy is required. While insulin is the traditional gold standard, oral hypoglycemic agents like glyburide or metformin are increasingly utilized for clients with unstable control who cannot manage or refuse injections. These agents help maintain euglycemia, reducing risks of macrosomia and neonatal hypoglycemia. Normal fasting blood glucose levels in pregnancy should be below 95 mg/dL.
Choice B rationale
Clients with gestational diabetes require frequent monitoring to ensure fetal safety and maternal health. Testing only 1 to 2 times per day is insufficient to capture the glycemic variability associated with meals and hormonal shifts. Standard practice typically involves checking blood glucose 4 to 7 times daily, including fasting and postprandial levels. This rigorous monitoring allows for precise adjustments in medical nutrition therapy or medication. Postprandial 1 hour levels should remain below 140 mg/dL.
Choice C rationale
Hemoglobin A1C reflects average blood glucose levels over the preceding 2 to 3 months. In gestational diabetes, the condition is often diagnosed late in the second trimester, and blood glucose can fluctuate rapidly due to placental hormones. Monitoring A1C every 1 to 2 months is not responsive enough for acute management. Daily capillary blood glucose monitoring is the primary tool for clinical decisions. Normal non-pregnant A1C is typically below 5.7 percent, but targets vary.
Choice D rationale
During the second and third trimesters, the placenta produces increasing amounts of human placental lactogen, growth hormone, and cortisol. these hormones create significant insulin resistance to ensure adequate glucose is available for the fetus. Therefore, insulin requirements actually increase significantly during this period rather than decreasing. Decreasing the dose would lead to maternal hyperglycemia and potential fetal complications. Insulin needs often double or triple by the end of the third trimester.
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Correct Answer is B
Explanation
Choice B rationale
Placenta previa occurs when the placenta implants in the lower uterine segment, partially or completely covering the internal cervical os. As the cervix begins to soften or dilate in the later stages of pregnancy, placental vessels are disrupted. This typically results in painless, bright red vaginal bleeding during the second or third trimester. This lack of pain is a hallmark sign that differentiates previa from other complications like placental abruption, where pain is prominent.
Choice A rationale
Excessive nausea and vomiting are clinical manifestations associated with hyperemesis gravidarum or potentially molar pregnancies, rather than placenta previa. While some nausea can occur in any pregnancy, it is not a diagnostic or reportable finding specifically linked to the malposition of the placenta. The primary concern in placenta previa is the risk of maternal hemorrhage and fetal compromise due to blood loss, which is why bleeding is the priority finding to report.
Choice C rationale
A rigid, board-like abdomen is a classic clinical finding associated with placental abruption, which is the premature separation of a normally implanted placenta. In abruption, blood often accumulates between the placenta and the uterine wall, causing high intrauterine pressure, severe pain, and uterine tenderness. In placenta previa, the uterus usually remains soft, relaxed, and non-tender because the bleeding is external and does not cause the same degree of intrauterine irritation.
Choice D rationale
Rectal pressure is commonly associated with the descent of the fetal head into the pelvis during the second stage of labor or may be felt during a ruptured ectopic pregnancy with hemoperitoneum. It is not a standard or expected finding for a client with placenta previa. The clinical focus for previa remains on the assessment of vaginal discharge and bleeding, avoiding digital vaginal exams, and monitoring for signs of hypovolemic shock if bleeding becomes heavy.
Correct Answer is B
Explanation
Choice A rationale
In the first trimester of pregnancy, clients with type 1 diabetes mellitus actually often require a decrease in their insulin dosage rather than an increase. This is due to increased insulin sensitivity and the consumption of glucose by the developing embryo. Additionally, nausea and vomiting associated with morning sickness can lead to decreased caloric intake, further reducing the need for exogenous insulin and increasing the risk of hypoglycemia during this early gestational period.
Choice B rationale
Polyphagia, or excessive hunger, is a classic clinical manifestation of diabetes mellitus and is frequently seen in clients with pregestational type 1 diabetes. Because the body cannot effectively transport glucose into the cells due to a lack of insulin, the cells remain starved for energy despite high circulating blood glucose levels. This intracellular starvation triggers the hunger center in the brain, leading to increased food intake as the body attempts to compensate for the perceived energy deficit.
Choice C rationale
Weight gain higher than recommended is not a finding specifically associated with the physiological pathology of pregestational type 1 diabetes mellitus. In fact, if the diabetes is poorly controlled and the body is unable to utilize glucose, it may begin breaking down fats and proteins for energy, which could potentially lead to weight loss or difficulty gaining weight. Excessive weight gain is more commonly associated with lifestyle factors or other complications such as gestational hypertension.
Choice D rationale
Hypotension is not a characteristic finding associated with pregestational type 1 diabetes mellitus. On the contrary, individuals with long-standing type 1 diabetes are at a significantly higher risk for developing chronic hypertension and preeclampsia during pregnancy due to underlying vascular damage and renal changes. Monitoring for elevated blood pressure, usually defined as 140/90 mmHg or higher, is a priority in the care of these clients to prevent adverse maternal and neonatal outcomes.
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