Maternal Risk FactorsMaternal Risk FactorsFetal AssessmentFetal Assessment

High Risk PregnancyHigh Risk Pregnancy

The life or health of the mother or The life or health of the mother or fetus is jeopardizedfetus is jeopardized

Examples include:Examples include:– GDMGDM– Previous lossPrevious loss– AMAAMA– HTNHTN– Abnormalities with the neonateAbnormalities with the neonate

Perinatal MortalityPerinatal Mortality

Overall maternal deaths are smallOverall maternal deaths are small Many deaths a preventableMany deaths a preventable Education and prenatal care are veryEducation and prenatal care are very

importantimportant

Antepartum TestingAntepartum Testing FKCs BIDFKCs BID UTZUTZ

– FHRFHR– Gestation ageGestation age– AbnormalitiesAbnormalities– IUGRIUGR– Placental location and qualityPlacental location and quality– AFIAFI– PositionPosition– BPPBPP– Doppler flowDoppler flow– Fetal growthFetal growth

UltrasoundUltrasound

Can be done abdominally or Can be done abdominally or transvaginallytransvaginally

11stst trimester done to detect viability, trimester done to detect viability, calculate EDCcalculate EDC

22ndnd trimester done to detect trimester done to detect anomalies, calculate EDCanomalies, calculate EDC

33rdrd trimester done to do BPP, fetal trimester done to do BPP, fetal growth and well-being, AFIgrowth and well-being, AFI

Doppler Flow Analysis via Doppler Flow Analysis via UTZUTZ

Study blood blow in the fetus and Study blood blow in the fetus and placentaplacenta

Done on high risk mothers:Done on high risk mothers:– IUGRIUGR– HTNHTN– DMDM– Multiple gestationMultiple gestation

AFIAFI

Polyhydramnios – too much amniotic Polyhydramnios – too much amniotic fluidfluid

Oligohydramnios – too little amniotic Oligohydramnios – too little amniotic fluidfluid

Biophysical ProfileBiophysical Profile

Includes 5 components:Includes 5 components:– Fetal breathing movementsFetal breathing movements– Gross body movementsGross body movements– Fetal toneFetal tone– AFIAFI– NST - reactiveNST - reactive

AmniocentesisAmniocentesis

Used with direct ultrasoundUsed with direct ultrasound Less than 1% result in complicationsLess than 1% result in complications

– Complications include:Complications include: Fetal death, miscarriageFetal death, miscarriage Maternal hemorrhageMaternal hemorrhage Infection to fetusInfection to fetus Preterm laborPreterm labor Leakage of amniotic fluidLeakage of amniotic fluid

MeconiumMeconium

Visual inspection of amniotic fluidVisual inspection of amniotic fluid Meconium is defined as thin and Meconium is defined as thin and

thick and particulate thick and particulate Associated with fetal stress: hypoxia, Associated with fetal stress: hypoxia,

umbilical cord compressionumbilical cord compression

CVSCVS

Done between 9 -12 weeksDone between 9 -12 weeks Genetic studiesGenetic studies Removal of small amount of tissue Removal of small amount of tissue

from the fetal portion of the placentafrom the fetal portion of the placenta Complications: vaginal spotting, Complications: vaginal spotting,

miscarriage, ROM, chorioamnionitismiscarriage, ROM, chorioamnionitis If done prior to 10 weeks, increased If done prior to 10 weeks, increased

risk of limb anomaliesrisk of limb anomalies

AFPAFP

Genetic testGenetic test Done with mothers bloodDone with mothers blood 16-20 weeks gestation16-20 weeks gestation Mandated by state of CaliforniaMandated by state of California

EFMEFM

Third trimester goal is to continue to Third trimester goal is to continue to observe the fetus within the observe the fetus within the intrauterine environmentintrauterine environment

Goal: dx uteroplacental insufficiencyGoal: dx uteroplacental insufficiency NST vs. CSTNST vs. CST

NSTNST

90% of gross fetal body movements are 90% of gross fetal body movements are associated with accelerations of the associated with accelerations of the FHRFHR

Can be performed outpatientCan be performed outpatient Not as sensitiveNot as sensitive User friendly but must interpret stripUser friendly but must interpret strip Fetus may be in a sleep state or Fetus may be in a sleep state or

affected by maternal medications, affected by maternal medications, glucose etc.glucose etc.

NSTNST

To be reactive must meet criteriaTo be reactive must meet criteria Must be at least 20 minutes in lengthMust be at least 20 minutes in length Must have 2 or more accelerations Must have 2 or more accelerations

that meet the ’15 X 15’ criteriathat meet the ’15 X 15’ criteria Must have a normal baselineMust have a normal baseline Must have LTVMust have LTV

NSTNST

To stimulate a fetus that is not To stimulate a fetus that is not meeting criteria:meeting criteria:– Change positions of the mother – LS, RSChange positions of the mother – LS, RS– Increase fluidsIncrease fluids– Acoustic stimulatorAcoustic stimulator

CSTCST

Done in the inpatient setting only!Done in the inpatient setting only! Has contraindicationsHas contraindications May be expensive if meds/IV neededMay be expensive if meds/IV needed Monitored for 10 minutes first Monitored for 10 minutes first Then may use nipple stimulation or Then may use nipple stimulation or

oxytocin stimulationoxytocin stimulation No late decelerations than negative No late decelerations than negative

CSTCST

CSTCST

Endocrine and Metabolic Endocrine and Metabolic DisordersDisorders

#1 Diabetes Mellitus#1 Diabetes Mellitus Disorders of the thyroidDisorders of the thyroid HyperemesisHyperemesis

DiabetesDiabetes

HyperglycemiaHyperglycemia May be due to inadequate insulin May be due to inadequate insulin

action or due to impaired insulin action or due to impaired insulin secretionsecretion

Type 1 – insulin deficiencyType 1 – insulin deficiency Type 2 – insulin resistanceType 2 – insulin resistance GDM – glucose intolerance during GDM – glucose intolerance during

pregnancypregnancy

DMDM

1010thth week fetus produces it own insulin week fetus produces it own insulin Insulin does not cross the placental Insulin does not cross the placental

barrierbarrier Glucose levels in the fetus and directly Glucose levels in the fetus and directly

proportional to the motherproportional to the mother 22ndnd and 3 and 3rdrd trimesters – decreased trimesters – decreased

tolerance to glucose, increased insulin tolerance to glucose, increased insulin resistance, increased hepatic function resistance, increased hepatic function of glucoseof glucose

Diabetic NephropathyDiabetic Nephropathy

Increased risks for:Increased risks for:– PreeclampsiaPreeclampsia– IUGRIUGR– PTLPTL– Fetal distressFetal distress– IUFDIUFD– Neonatal deathNeonatal death

DMDM

Poor glycemic control is associated Poor glycemic control is associated with increased risks of miscarriage at with increased risks of miscarriage at time of conceptiontime of conception

Poor glycemic control in later part of Poor glycemic control in later part of pregnancy is assoc. with fetal pregnancy is assoc. with fetal macrosomia and polyhydramniosmacrosomia and polyhydramnios

PolyhydramniosPolyhydramnios

May compress on the vena cava and May compress on the vena cava and aorta causing hypotension, PROM, PP aorta causing hypotension, PROM, PP hemorrhage, maternal dyspneahemorrhage, maternal dyspnea

MacrosomiaMacrosomia

Disproportionate increase in shoulder Disproportionate increase in shoulder and trunk sizeand trunk size

4000-4500gms or greater4000-4500gms or greater Fetus will have excess stores of Fetus will have excess stores of

glycogenglycogen Increased risks ofIncreased risks of

– Shoulder dystociaShoulder dystocia– C/SC/S– Assisted deliveriesAssisted deliveries

IUGRIUGR

Compromised uteroplacental Compromised uteroplacental insufficiencyinsufficiency

02 available to the fetus is decreased02 available to the fetus is decreased

RDSRDS

Increased RDS due to high glucose Increased RDS due to high glucose levelslevels

Delays pulmonary maturityDelays pulmonary maturity

Neonatal HypoglycemiaNeonatal Hypoglycemia

Usually 30-60 minutes after birthUsually 30-60 minutes after birth Due to high glucose levels during Due to high glucose levels during

pregnancy and rapid use of glucose pregnancy and rapid use of glucose after birthafter birth

Related to mothers level of glucose Related to mothers level of glucose controlcontrol

Labs with DMLabs with DM

HBA1cHBA1c 1 hour PP1 hour PP FBSFBS

DietDiet

Sweet success dietSweet success diet Well balanced dietWell balanced diet 6 small meals / day6 small meals / day Have snack at HSHave snack at HS Never skip mealsNever skip meals Avoid simple sugarsAvoid simple sugars

InsulinInsulin

Regular/Lispro and NPHRegular/Lispro and NPH 2/3 dose in am and 1/3 dose in pm2/3 dose in am and 1/3 dose in pm

Monitoring Glucose LevelsMonitoring Glucose Levels

FBSFBS 1 hour PP1 hour PP HSHS 5 checks / day5 checks / day

Fetal SurveillanceFetal Surveillance

NSTs done around 26 weeks, weeklyNSTs done around 26 weeks, weekly

At 32 weeks done biweekly with At 32 weeks done biweekly with NST/BPPNST/BPP

Infections and DMInfections and DM

Infections are increased:Infections are increased:– CandidiasisCandidiasis– UTIsUTIs– PP infectionsPP infections

DMDM

Increased risk of IUFD after 36 weeksIncreased risk of IUFD after 36 weeks Increased congenital anomaliesIncreased congenital anomalies

– Cardiac defectsCardiac defects– CNS defectsCNS defects

Spina bifidaSpina bifida anencephalyanencephaly

– Skeletal defectsSkeletal defects

DM and laborDM and labor

Continuous fetal monitoringContinuous fetal monitoring Blood glucose levels in tight controlBlood glucose levels in tight control Be prepared for CPDBe prepared for CPD

GDMGDM

Women with GDM at risk of Women with GDM at risk of developing DM later on in lifedeveloping DM later on in life

NSTs around 28 weeksNSTs around 28 weeks

HyperthyroidismHyperthyroidism

Typically caused by Grave’s diseaseTypically caused by Grave’s disease S/S: S/S:

– FatigueFatigue– Heat intoleranceHeat intolerance– Warm skinWarm skin– DiaphoresisDiaphoresis– Weight lossWeight loss

Should be treated in pregnancyShould be treated in pregnancy Tx with PTUTx with PTU Beta blockersBeta blockers May lead to thyroid storm if May lead to thyroid storm if

untreateduntreated

HypothyroidismHypothyroidism

Usually caused by Hashimoto’sUsually caused by Hashimoto’s S/S:S/S:

– Weight gainWeight gain– Cold intoleranceCold intolerance– FatigueFatigue– Hair lossHair loss– ConstipationConstipation– Dry skinDry skin

Tx with thyroid hormones such as Tx with thyroid hormones such as synthroid or levothyroxinesynthroid or levothyroxine

Maintain TSH wnlMaintain TSH wnl Checked periodically throughout the Checked periodically throughout the

pregnancypregnancy

Cardiovascular DisordersCardiovascular Disorders

The heart must compensate for the The heart must compensate for the increased workloadincreased workload

If the cardiac changes are not well If the cardiac changes are not well tolerated than cardiac failure can tolerated than cardiac failure can developdevelop

1% of pregnancies are complicated 1% of pregnancies are complicated by heart diseaseby heart disease

NY Heart Association NY Heart Association ClassesClasses

Class IClass I Class IIClass II Class IIIClass III Class IVClass IV

Cardiac output is increased Cardiac output is increased Peak of the increase 20-24 weeks Peak of the increase 20-24 weeks

gestationgestation Cardiac problems should be Cardiac problems should be

managed with cardiologistmanaged with cardiologist Mortality with pulmonary Mortality with pulmonary

hypertension and pregnancy is more hypertension and pregnancy is more than 50%than 50%

Diet: low sodiumDiet: low sodium

Nursing CareNursing Care

Avoiding anemiaAvoiding anemia Avoid strenuous activityAvoid strenuous activity Monitor for: cardiac failure and Monitor for: cardiac failure and

pulmonary congestionpulmonary congestion

During LaborDuring Labor

Side lying positionSide lying position Prophylactic antibioticProphylactic antibiotic EpiduralEpidural Attempt vaginal deliveryAttempt vaginal delivery If anticoagulant therapy is needed:If anticoagulant therapy is needed:

– Heparin Heparin – LovenoxLovenox

MVPMVP

Common and usually benignCommon and usually benign May experience syncope, palpitations May experience syncope, palpitations

and dyspneaand dyspnea Prophylactic antibiotics given before Prophylactic antibiotics given before

invasive procedure or birthinvasive procedure or birth

AnemiaAnemia

Most common iron deficiencyMost common iron deficiency Hgb falls below 12 (most labs)Hgb falls below 12 (most labs) Typically seen in the end of 2Typically seen in the end of 2ndnd

trimestertrimester Iron supplementationIron supplementation

Folic Acid Deficiency Folic Acid Deficiency AnemiaAnemia

Increases risk of NTD, cleft lipIncreases risk of NTD, cleft lip Recommended dose 400 mcg/dayRecommended dose 400 mcg/day Supplemented in cereal and many Supplemented in cereal and many

other foodsother foods

Sickle Cell AnemiaSickle Cell Anemia

Abnormal hemoglobin SS types in the Abnormal hemoglobin SS types in the bloodblood

People have recurrent attacks of People have recurrent attacks of fever and pain in the abdomen and fever and pain in the abdomen and extremitiesextremities

Caused from tissue hypoxia, edemaCaused from tissue hypoxia, edema African-AmericansAfrican-Americans

Sickle Cell TraitSickle Cell Trait

Typically asymptomaticTypically asymptomatic Sickling of the RBCs but with a Sickling of the RBCs but with a

normal RBC life spannormal RBC life span

ThalassemiaThalassemia

Common anemiaCommon anemia Insufficient amount of Hgb is Insufficient amount of Hgb is

produced to fill the RBCsproduced to fill the RBCs Mediterranean regionMediterranean region Genetic disorderGenetic disorder May be associated with LBW babies May be associated with LBW babies

and increased fetal deathand increased fetal death

AsthmaAsthma

Common with FHCommon with FH 1-4% of pregnant women have Asthma1-4% of pregnant women have Asthma Possible adverse events associated Possible adverse events associated

with asthma:with asthma:– LBWLBW– Perinatal mortalityPerinatal mortality– PreeclampsiaPreeclampsia– Complicated laborComplicated labor– HyperemesisHyperemesis

Asthma ContinuedAsthma Continued

Goal is to relieve the attack, prevent Goal is to relieve the attack, prevent the asthma attack, and maintain 02the asthma attack, and maintain 02

Should be managed with OB and ENTShould be managed with OB and ENT May require tx: albuterol, steroids, May require tx: albuterol, steroids,

O2O2

EpilepsyEpilepsy

Seizure disorderSeizure disorder May result from developmental May result from developmental

abnormalities or injuryabnormalities or injury 20% have an increase in seizure 20% have an increase in seizure

activity during pregnancyactivity during pregnancy Risks: more seizures, risk of vaginal Risks: more seizures, risk of vaginal

bleeding, abruptio placentae, fetus bleeding, abruptio placentae, fetus may experience seizuresmay experience seizures

Epilepsy ContinuedEpilepsy Continued

Use of antiepeleptic meds during Use of antiepeleptic meds during pregnancy has been linked to risks pregnancy has been linked to risks for the fetusfor the fetus

Smallest therapeutic dose to be Smallest therapeutic dose to be givengiven

Daily folic acid supplementationDaily folic acid supplementation Managed with OB and neurologistManaged with OB and neurologist

RARA

Chronic arthritisChronic arthritis Pain upon movement and swelling in Pain upon movement and swelling in

joint spacesjoint spaces More often in womenMore often in women 2/3 of women with RA find the 2/3 of women with RA find the

severity of symptoms decrease severity of symptoms decrease during pregnancyduring pregnancy

Typically give baby ASATypically give baby ASA

SLESLE

Inflammatory disease, autoimmune Inflammatory disease, autoimmune antibody productionantibody production

Advised to wait until in remission for Advised to wait until in remission for 6 months to become pregnant6 months to become pregnant

15-60% of women will develop 15-60% of women will develop exacerbation of SLE during exacerbation of SLE during pregnancy or postpartumpregnancy or postpartum

Tx: ASA and steroidsTx: ASA and steroids

CholelithiasisCholelithiasis

More often in womenMore often in women Pregnancy makes women more Pregnancy makes women more

vulnerablevulnerable Surgery often delayed until after Surgery often delayed until after

deliverydelivery

AppendicitisAppendicitis

Dx may take more time to findDx may take more time to find Sxs: abdominal pain, nausea, Sxs: abdominal pain, nausea,

vomiting, loss of appetitevomiting, loss of appetite Increases incidence of PTL or SABIncreases incidence of PTL or SAB

Maternal InfectionsMaternal Infections

TORCHTORCH

Toxoplasmosis – protozoan infection, Toxoplasmosis – protozoan infection, neonatal effects – jaundice, neonatal effects – jaundice, hydrocephalus, microcephalyhydrocephalus, microcephaly

Other- Heb A or B, Group B, Varicella, Other- Heb A or B, Group B, Varicella, HIVHIV

Rubella (German measles) – if Rubella (German measles) – if contracted in 1contracted in 1stst Trimester fetus may Trimester fetus may have congenital deformitieshave congenital deformities

TORCHTORCH

CMV- transmitted person to person, CMV- transmitted person to person, may cause CNS damage to fetusmay cause CNS damage to fetus

Herpes Simplex (HSV 2) – if initial Herpes Simplex (HSV 2) – if initial infection occurs in pregnancy, higher infection occurs in pregnancy, higher incidence of perinatal loss. Fetus incidence of perinatal loss. Fetus may pick up virus if present in the may pick up virus if present in the vagina during laborvagina during labor

Mental Health Mental Health DisordersDisorders

Anxiety DisordersAnxiety Disorders

Most common mental disordersMost common mental disorders Include: phobias, panic disorders, Include: phobias, panic disorders,

OCD, PTSDOCD, PTSD Tx: relaxation techniques, breathing Tx: relaxation techniques, breathing

exercises, imageryexercises, imagery

Depression in PregnancyDepression in Pregnancy

6% of women develop depression for 6% of women develop depression for the 1the 1stst time during pregnancy time during pregnancy

Tx: counseling and tx with SSRIsTx: counseling and tx with SSRIs Wellbutrin only med named as Wellbutrin only med named as

Category BCategory B Many women opt to DC meds during Many women opt to DC meds during

pregnancypregnancy

Substance Abuse in Substance Abuse in PregnancyPregnancy

Substance AbuseSubstance Abuse

Damaging effects well documented in Damaging effects well documented in research to fetusresearch to fetus

Any use of ETOH or illicit drugs during Any use of ETOH or illicit drugs during pregnancy is considered abusepregnancy is considered abuse

31% of women had used one or more 31% of women had used one or more substances during pregnancy (as substances during pregnancy (as compared to 62% during compared to 62% during prepregnancy)prepregnancy)

SmokingSmoking

Risks of any amount of smoking Risks of any amount of smoking include:include:– SABSAB– SGASGA– BleedingBleeding– IUFDIUFD– PrematurityPrematurity– SIDSSIDS

AlcoholAlcohol

Many women reluctant to tell health Many women reluctant to tell health care providercare provider

Risks:Risks:– LBWLBW– Mental retardationMental retardation– Learning and physical deficitsLearning and physical deficits– With FAS – severe facial deformitiesWith FAS – severe facial deformities

Alcohol during PregnancyAlcohol during Pregnancy

Risks to mother:Risks to mother:– HTNHTN– AnemiaAnemia– Nutritional deficitsNutritional deficits– PancreatitisPancreatitis– CirrhosisCirrhosis– Alcoholic hepatitisAlcoholic hepatitis

MarijuanaMarijuana

Crosses the placenta and causes Crosses the placenta and causes increased carbon monoxide levels in increased carbon monoxide levels in mother’s bloodmother’s blood

May cause fetal abnormalitiesMay cause fetal abnormalities

CocaineCocaine

In the US, 10-15% of all pregnant In the US, 10-15% of all pregnant women use cocainewomen use cocaine

Problems associated with use: Problems associated with use: polydrug use, poor health, poor polydrug use, poor health, poor nutrition, STIs, infections, HIVnutrition, STIs, infections, HIV

Poverty big issuePoverty big issue

Cocaine in PregnancyCocaine in Pregnancy

Maternal effects:Maternal effects:– Cardiovascular Cardiovascular

stressstress– TachycardiaTachycardia– HTNHTN– DysrhythmiasDysrhythmias– MIMI– Liver damageLiver damage– SzSz– Pulmonary diseasePulmonary disease– DeathDeath

Fetal Fetal Complications:Complications:– Abruptio placentaeAbruptio placentae– PTLPTL– Precipitous laborPrecipitous labor– Risks for abdominal Risks for abdominal

pregnancypregnancy– Fetal complications Fetal complications

after deliveryafter delivery

Opiates in PregnancyOpiates in Pregnancy

Drugs include: heroin, Demerol, Drugs include: heroin, Demerol, morphine, codeine, methadonemorphine, codeine, methadone

Methadone is used to treat addiction Methadone is used to treat addiction to other opiatesto other opiates

Possible effects on pregnancy and Possible effects on pregnancy and heroin use are: Preeclampsia, PROM, heroin use are: Preeclampsia, PROM, infections, PTLinfections, PTL

Tx: Methadone and psychotherapyTx: Methadone and psychotherapy Goal: prevent withdrawal symptomsGoal: prevent withdrawal symptoms

MethamphetamineMethamphetamine

CNS stimulantCNS stimulant Most common use n the 18-30 yr old Most common use n the 18-30 yr old

rangerange Neonatal complications include:Neonatal complications include:

– IUGRIUGR– PRL/PTBPRL/PTB

Postpartum Postpartum Psychologic Psychologic

ComplicationsComplications

Baby BluesBaby Blues

Usually within 4 weeks of childbirthUsually within 4 weeks of childbirth Many experience thisMany experience this

PPDPPD

Intense sadness, crying all the time, Intense sadness, crying all the time, mood swings, fears, anger, anxiety, mood swings, fears, anger, anxiety, irritabilityirritability

Incidence of PPD at 8 weeks – 12% Incidence of PPD at 8 weeks – 12% and 8% at 12 weeksand 8% at 12 weeks

Many women feel guiltyMany women feel guilty May need tx but usually resolves on May need tx but usually resolves on

ownown

Postpartum PsychosisPostpartum Psychosis

Delusions, hurting self or the infant, Delusions, hurting self or the infant, emotional lability, insomnia, emotional lability, insomnia, suspiciousness, confusion, obsessive suspiciousness, confusion, obsessive concerns regarding the babyconcerns regarding the baby

1-2/1000 births1-2/1000 births 35-60% recurrence with each 35-60% recurrence with each

subsequent birthsubsequent birth Usually symptoms appear within 8 Usually symptoms appear within 8

weeks of birthweeks of birth

Medical ManagementMedical Management

Supportive familySupportive family Intense psychotherapyIntense psychotherapy EmergencyEmergency Tx: SSRIsTx: SSRIs SSRIs contraindicated while SSRIs contraindicated while

breastfeedingbreastfeeding

1. A client asks the nurse to again 1. A client asks the nurse to again explain the purpose of the explain the purpose of the amniocentesis test. The nurse amniocentesis test. The nurse responds that one purpose of this test responds that one purpose of this test is to indicate the:is to indicate the:– A. Accurate age of the fetusA. Accurate age of the fetus– B. Presence of certain congenital B. Presence of certain congenital

anomaliesanomalies– C. Biparietal diameter of the skullC. Biparietal diameter of the skull– D. Hormone content of the amniotic fluidD. Hormone content of the amniotic fluid– E. Mainly the presence of Down’s E. Mainly the presence of Down’s

syndrome syndrome

2. The nurse explains to a new 2. The nurse explains to a new mother that the condition of SGA is mother that the condition of SGA is caused by:caused by:– A. Placental insufficiencyA. Placental insufficiency– B. Maternal obesityB. Maternal obesity– C. PrimiparaC. Primipara– D. Genetic predispositionD. Genetic predisposition

3. A pregnant client with diabetes is 3. A pregnant client with diabetes is controlled by insulin. When she asks the controlled by insulin. When she asks the nurse what will happen to her insulin nurse what will happen to her insulin requirements during pregnancy, the correct requirements during pregnancy, the correct response is:response is:– A. “Because your case is so mild, you are likely A. “Because your case is so mild, you are likely

not to need much insulin during your not to need much insulin during your pregnancy”pregnancy”

– B. “It’s likely that as the pregnancy progresses B. “It’s likely that as the pregnancy progresses you will need increased insulin”you will need increased insulin”

– C. “Every case is individual so there is really no C. “Every case is individual so there is really no way to know”way to know”

– D. “If you follow the diet closely and don’t gain D. “If you follow the diet closely and don’t gain too much weight, your insulin needs should stay too much weight, your insulin needs should stay the same”the same”

4. The nurse in the newborn nursery 4. The nurse in the newborn nursery understands that assessing a understands that assessing a newborn with a diabetic mother, newborn with a diabetic mother, initially the insulin level would be:initially the insulin level would be:– A. Higher than in normal infantsA. Higher than in normal infants– B. Lower than in normal infantsB. Lower than in normal infants– C. The same as in normal infantsC. The same as in normal infants– D. Varied from baby to babyD. Varied from baby to baby

5. A client is admitted to L&D, at 38 5. A client is admitted to L&D, at 38 weeks gestation. She is there for weeks gestation. She is there for evaluation because she is evaluation because she is experiencing polyhydramnios. The experiencing polyhydramnios. The nurse understands that this diagnosis nurse understands that this diagnosis means that:means that:– A. There is the normal amount of A. There is the normal amount of

amniotic fluid, thinner in volumeamniotic fluid, thinner in volume– B. A less-than-normal amount of amniotic B. A less-than-normal amount of amniotic

fluid is presentfluid is present– C. An excessive amount of amniotic fluid C. An excessive amount of amniotic fluid

is presentis present– D. A leak is causing the fluid to D. A leak is causing the fluid to

accumulate outside the amniotic sacaccumulate outside the amniotic sac