1. W/c of the ff is NOT a classic manifestation of pregnancy-induced hypertension (PIH)? 8. A patient who is 35 weeks pregnant has gestational diabetes.

is 35 weeks pregnant has gestational diabetes. Which laboratory result for blood glucose is euglycemic?
A.3+ edema A. 55 mg/dl
B. Blood pressure of 160/110 mmHg B. 82 mg/dl
C. Epigastric pain C. 148 mg/dl
D. Protein 2+ random urine sample D. 200 mg/dl

2. W/c of the ff is NOT a commonly associated risk fx for PIH? 9. A 32-year-old pregnant female is diagnosed with gestational diabetes at 28 weeks gestation. As the nurse, you know that
A. 1st pregnancy @ the age of 17 y/o the test below is used to diagnose a patient with this condition:
B. Multiple gestation A. 1- hour glucose tolerance test
C. Multiple pregnancies B. 24-hour urine test
D. Ovarian cancer C. Hemoglobin A1C
D. 3-hour glucose tolerance test
3. When administering hydralazine on a client with PIH, the nurse carefully monitors which of the following as indicator of
effectiveness? 10. When do most patients tend to develop GDM during pregnancy?
A. Blood pressure A. 1st to 3rd month
B. Edema grading B. 2nd to 3rd month
C. Heart rate C. 1st to 2nd trimester
D. Platelet count D. 2nd to 3rd trimester

4. Which of the following, if noted on a client taking aspirin 81 mg PO OD for PIH should be further evaluated & reported to the
physician immediately?
1. The underlying difference between eclampsia & preeclampsia lies on the presence of:
A. Black tarry stool
B. Hyperactive bowel sounds
C. Respiration at 10 bpm i A seizure
D. Variable deceleration on fetal monitor ii Blood pressure reading
iii High urine specific gravity
iv Proteinuria
5. To which assessment finding, if noted should the nurse be most concern on a client with severe preeclampsia?
A. Blood pressure of 170/110 mmHg
2. The nurse understands that if the client is to be started on magnesium sulfate infusion, which item should also be available in
B. Epigastric pain
C. Halo vision the unit for emergency use?
D. Hypoactive bowel sounds
i Calcium gluconate
6. When are pregnant patients tested for gestational diabetes? ii Diazepam (Valium)
A. 6 to 12 weeks AOG iii Endotracheal tube
B. 12 to 20 weeks AOG iv Suction apparatus
C. 24 to 28 weeks AOG
D. 30 to 32 weeks AOG 3. The nurse implements which of the following as a priority key area on a client during a seizure caused by eclampsia?

7. The nurse educates the pregnant patient with gestational diabetes that she should try to have a blood glucose level of i Airway
________ 1 hour after a meal: ii Breathing
A. < 70 mg/dl iii Circulation
B. < 140 mg/dl iv Fetal well being
C. < 160 mg/dl
D. 250 mg/dl 4. A pregnant client with a blood pressure reading of 150/90 mmHg taken on two occasions who does not exhibit proteinuria &
edema is classified as having:
 1. Fasting of more than 95mg/dL
i Eclampsia 2. Fasting of less than 95mg/dL
ii Gestational hypertension 3. After 1 hour, more than 180mg/dL
iii Preeclampsia with severe features 4. After 3 hours, less than 140mg/dL
iv Preeclampsia without severe features
i 1&3
5. While receiving a client with ongoing magnesium sulfate infusion, the nurse considers which of the following, when noted, as ii 1&4
requiring immediate infusion discontinuation & notification to the physician? iii 2&3
iv 2&4
i Diminished responsiveness
ii Heart rate of 51 bpm 9. During a glucose tolerance test how much concentration of glucose will the nurse give to the pregnant woman?
iii Shallow rapid respirations
iv Shooting blood pressure reading
i 50 grams
ii 75 grams
6. When does the increase in the serum glucose usually develop during pregnancy? iii 100 grams
i 14- 16 weeks iv 150 grams
ii 20-24 weeks
iii 20-26 weeks
iv 26-28 weeks
10. The patient is scheduled for an alpha-fetoprotein level test. She feels anxious about what this test is. The nurse explains that
7. A pregnant woman with gestational diabetes asks the nurse what she’s going to feel in case, she omits her meals. The nurse this test is done to determine:
informs her that she’s going to experience the following:
i the daily amount of protein
i Diaphoresis, pallor, headache, dry mouth ii the size of the fetus
ii Increase thirst, frequent urination, increased hunger, irritability iii the gross abnormalities & condition of the placenta
iii Diaphoresis, pallor, light-headedness, tingling around the mouth iv birth anomalies & genetic disorders.
iv Glycosuria, weakness, headache, confusion

8. Which of the following results of glucose tolerance test will confirm the diagnosis of gestational diabetes?

🍏 Introduction on PIH as a High-Risk Pregnancy Condition ◘ ASSESSMENT

Pregnancy-Induced HTN (PIH) “Gestational HTN” Should be focused on maternal Hx (inclusive of associated risk fxs to establish causation) &
- HIGH-risk pregnancy condition, HTN in [Pregnancy] resulting from vasospasm of small & LARGE arteries. presenting clinical manifestations. PIH’s cause is unknown, it is commonly related w/ the ff risk fxs:

- Dvlopment of HTN that is caused by [Pregnancy] 1. Antiphospholipid Syndrome (APS)

- Main reason as to why it develops is largely UNKNOWN. Clients w/ APS often exhibit strongest association to cases of PIH.
There are fxs r/t the dvlopment of PIH but none of them is the Direct reason for the disease occurence
While the causal relationship of APS to PIH is NOT fully established, the presence of ✓autoantibodies directed against
phospholipid layer of the blood vessels can cause THROMBOSIS & diminished circulation, similar w/ PIH.
Vasospasm
- Causes ↑d vascular resistance
2. Women of color. Although NOT fully understood, ↑↑Black women tend to show more cases of PIH.
- W/c causes the heart ♥ to ↑ s PRESSURE to perfuse systemic organs, including ✓Uterus
- Previously termed as “toxemia” of pregnancy 3. Multiple pregnancies
as it was believed to be caused by a toxin in response to a foreign protein that form a growing fetus° The required ↑ in the CO in pregnancy
↓↓axn of Prostacyclin (vasoDILATOR) & ↑s thromboxane (vasoconstrictor).
🍏 Nrsg Care Management of Clients w/ a PIH thru the Application of the Nrsg Process ↓ing vasodilation (↓low Prostacyclin) & ↑ing vasoconstriction (↑↑high Thromboxane)
APPLICATION of the NRSG PROCESS
 generally lead to Artery Vasoconstriction & Vasospasm.
🖸Prostaglandin release in pregnancy causes ↑ing effects of Angiotensin & Norepinephrine in PIH.
Normal pregnancy, ↑d CO still places the BP w/in normal ranges bc BLOOD vessels are NOT affected by Angiotensin &
Norepinephrine. These justifications are also applicable to Multiparity as an associated risk fx for PIH.
4. Multiparity Women who have had 5/ ↑↑more pregnancies = tend to show ↑incidence of PIH.
5. Primiparas younger than 20 years old or older than 40 years old.
Teenage population, PIH has a prevalence twice (2x) as high as that in the Adult population.
Advancing age may be associated w/ possible presence of ✓comorbidities that include Diabetes & HTN.
6. Low socioeconomic status. Underlying POOR nourishment of both Mother & fetus° can contribute to devt of PIH.
7. Polyhydramnios
Characterized by ↑↑Amniotic fluid accumulation [during pregnancy], Is believed to be associated w/ devt of PIH but
causation remains UNCLEAR.
8. Underlying co-morbidities (heart disease, diabetes, hypertension, renal disease)
These conditions are thought to ↑ susceptibility in the devt of HTN [during pregnancy].
Symptomatology in PIH emerges beginning abt the 20th wk of pregnancy.
CLASSIC MANIFESTATIONS of PIH are Proteinuria, EDEMA & HTN.
When a client w/ a PIH is presented in the maternity unit,
the N. must specifically look in his assessment the ff clinical manifestations of the dse that commonly include:
1. HTN
The associated uterine artery vasospasm causes
↑d Peripheral Vascular Resistance (d/ t ↓↓ Prostacyclin & ↑↑ Thromboxane; ↑d effects of Angiotensin & Norepinephrine).
BP readings are somewhat important in the classification of a PIH
The associated Vasospasm can also ↑ platelet aggregation inside BLOOD vessel walls.
2 CRITERIA to remember when N. measures & documents BP reading in a PIH:
○ BP of @ least 140/90 mmHg
BP must be taken on 2 separate occasions @ least [6 hrs apart]
Diastolic pressure = extremely important, Indicator of degree of peripheral arterial spasm/ resistance.
○ Comparison of pregnancy & pre-pregnancy BP readings
Systolic BP (≥)/ ↑ 30 mmHg & a diastolic BP (≥)/ ↑ 15 mmHg from pre-pregnancy values establish a PIH.
If [pre-pregnancy BP] = 90/50 mmHg ;; [pregnancy BP] = 120/65 mmHg can suggest significant elevation./ ✓PIH
🖸 If X baseline pre-pregnancy is determined during clinical assessment (Late prenatal checkup). = A cut off is 140/90 mmHg
2. Proteinuria
The renal changes caused by ↑ing Vasospasm in a PIH favor loss of proteins, particularly ✰Albumin, in the urine leading to
proteinuria/ albuminuria. The degree of proteinuria helps in the classification of a PIH.
The N must be able to review Lab results & must remember that the loss of protein in the urine can either be determined thru:
○Random urine sample
Reading of 1+ = 1g/L loss of protein in the urine on reagent test strip. ✓Proteinuria = said to have existed by 1+
3+ or 4+ reading = ✓Proteinuria.
○24-hour urine collection
Urine collection over a 24-hr period can reveal proteinuria & may register 5g or protein loss w/c marked ✓proteinuria
3. EDEMA (Wt gain, skin indenting).
i. This develops primarily d/t the loss of protein.
↓protein (=) ↓ colloid oncotic PRESSURE that allows movement of H2O from INTRAvascular into INTERstitial spaces.
ii. ALSO d/to effects of Na retention & POOR Glomerular Filtration Rate (caused by renal changes) [during pregnancy].
The N., in his assessment of the client w/ EDEMA should particularly look for signs of fluid ACCUMULATION that lead often to:
○ Wt GAIN
Wt gain of ↑↑more than 2 pounds/ week in [2nd trimester] or 1 pound/week in [3rd trimester]
= significant EDEMA,/ abnormal fluid accumulation.
🖸The N. should measure the extent of Wt. gain by checking on the client’s Wt. @ the same time each day,
w/ the same clothes & a similar weighing scale.
○Skin indenting
EXTREME EDEMA = mostly noticeable over bony surfaces(Tibia on {Anterior leg, {Ulnar surface of forearm, cheekbones).
NON-pitting EDEMA = ↑↑more SEVERE form of fluid accumulation (all interstitial spaces have been filled by fluid),
= described as the X indenting w/ finger PRESSURE.
Fluid accumulation can be palpated & the presence of ✓indenting describes EDEMA as Pitting.
If PITTING, N. can also evaluate & document EDEMA in terms of grade such as:
1+: @t least 2 mm depression; barely detectable; immediate rebound; mild
2+: @ least 4 mm depression; a few secs to rebound; moderate
3+: @ least 6 mm depression; 10 - 12 secs to rebound; severe
4+: @ least 8 mm depression; takes ↑↑more than 20 secs to rebound; very severe
4. ↓d urine output
Aggravating EDEMA = indicates that fluid in the intravascular spaces is diminishing
w/c also means that there’s inadequate renal tissue perfusion.
Along w/ existing HTN, the client’s urine output will ↓ owing to RENAL TISSUE DAMAGE
Thru Lab results: ↑Serum CREATININE (↑sensitive) & ↑Blood urea nitrogen (BUN) = indicator of Renal tissue damage
N. may encounter a client w/ Preeclampsia w/ SEVERE features to reveal urine output of 400-600 mL per 24 hours.
Accurate urine output monitoring = suggests the degree of Renal tissue perfusion.
5. Neurologic Disturbances
(HYPERactive patellar reflex & ankle clonus; Visual changes; Headache; Convulsion/ seizure).
While the cause of neurologic disturbances, specifically convulsion is UNKNOWN,
MAIN explanation is thought to be related w/ BP of @ least 140/90 mmHg
Cerebral artery spasm (d/t ↓↓Prostacyclin, ↑↑Thromboxane, ↑↑Angiotensin & ↑↑Norepinephrine); & 1 Gestational HTN (≥ 30 mmHg & 15 mmHg for Sys- & Dias- BP respectively from pre-pregnancy values)
Cerebral EDEMA (d/t ↓↓colloid oncotic PRESSURE & ↓↓Proteinuria). X Proteinuria; X EDEMA
Visual changes (Ex. flashing lights, blurred vision, floaters)=believed to be caused by spasm of Brain’s arteries BP w/in normal range after birth
(✰Cerebellum BP readings similar w/ gestational HTN
HYPERactivity of reflexes (Ex. patellar reflex) & 2 Preeclampsia w/o SEVERE features ✓Proteinuria (1+ – 2+ on Random urine sampling)
(Mild Preeclampsia) Wt gain over 2 pounds/ wk [2nd trimester]; 1 pound/ wk [3rd trimester]
Presence of ✓ankle clonus are indicative of Neuronal excitability & irritability. Mild EDEMA(upper extremities/ face)
BP of @ least 160/110 mmHg
N., in his assessment of a client w/ neurologic disturbance that the client’s condition is getting SEVERE ✓Proteinuria (3+ – 4+ on Random urine sampling; or 5g in 24-hr urine collection)
→ Can lead to Eclampsia = ↑↑more SEVERE classification of a PIH 3 Preeclampsia w/ SEVERE features Urine output = ≤ 500 ml over 24 hrs
(SEVERE Preeclampsia) ↑↑Elevated serum creatinine (↑↑more than 1.2 mg/dl)
Neurologic disturbances (Headache, Blurred vision)
Hepatic dysfnxn (Epigastric PAIN)
To determine the presence of ✓Ankle clonus, N. should perform the ff in succession: ✓SEIZURE/ COMA w/ S/Sxs of preeclampsia (edema, HTN, proteinuria)
4 Eclampsia Poor fetal prognosis°
a. Dorsiflex the client’s foot for 3x times in rapid succession.
It even becomes GRAVER when there is ✓Premature separation of the placenta
b. While taking the Hand away [N.’s], observe the Foot.
c. X of movement of Foot (=) X Ankle clonus. ◘DIAGNOSIS
Presence of ✓Involuntary movement = Clonus & the N. can grade his assessment as: Choice of Nrsg interventions is influenced by the N.’s assessment of the client’s presenting clinical manifestations & the
Mild: 2 movements effects that both the mother & the growing fetus° can encounter. Depends on client’s manifestations, Dxs generally
include
Moderate: 3 - 5 movements
1. Ineffective tissue perfusion r/t vasoconstriction of BLOOD vessels
SEVERE: over 6 movements As Vasospasm can greatly affect perfusion of the Uterus, Brain, Liver & Kidneys in the pathogenicity of PIH.
↓ing perfusion of tissues in PIH is responsible in causing fetal hypoxia°, neurologic disturbances
To assess for Patellar reflex, the N. may perform the ff steps: (Headache, Visual changes, Clonus, Seizure), Epigastric PAIN & Renal damage.
a. Tell the client to assume a {Supine position
b. Ask the client to bend her Knee slightly 2. Deficient fluid volume r/t fluid loss in SQ tissues/ interstitial space
c. Place the hand [N.’s] under the client’s Knee to support the leg. While EDEMA formation commonly requires fluid vol excess as a nrsg Dx, Deficient fluid vol is applicable in the
d. Locate the Patellar tendon in the midline of the {Anterior leg just below the kneecap. context of loss of intravascular fluid since shifting of fluid into the interstitial space has occurred.
e. Strike the client’s patellar tendon firmly & quickly w/ a Reflex hammer. This greatly diminishes perfusion of major organs since water is a major component of blood volume.
f. Note for the presence of movement of the foot. To aid the Physician in the 3. Risk for fetal injury r/t ↓↓reduced placental perfusion 2ndary to Vasospasm
✓movement (=) ✓Patellar reflex. The N. grades his assessment of the client as: classification of the client’s
Presence of ✓Uterine artery vasospasm can greatly ↓ the amount of blood flow into the placenta for fetal O2ation.
PIH, the N. plays a crucial
0: X response; hypoactive; abnormal Fetal distress° can occur owing to Hypoxia & the Risk for fetal organ damage ↑s w/ poorly controlled PIH.
role in the assessment of
the client. 4. Social isolation related to prescribed bedrest
1 somewhat diminished response but NOT abnormal
The envt that is suitable for a Preeclamptic mother (especially for SEVERE type) should be dimmed w/ minimal
+:
It NOT only helps in interruptions & noise lvl is kept to a minimum. D/t the required envtal manipulation to prevent seizure to occur, a feeling of
2 average (normal) response
priority of care of the client being socially isolated is possible & the N. must be able to carefully plan interventions to address this problem.
+:
but also her prognosis.
3 brisker than average but NOT abnormal
◘PLANNING
+: Classification, Dependent Plan of care should be directed @ an interplay b/w pharmacologic & NON-pharmacologic measures; & combination of
4 HYPERactive; very brisk; abnormal on symptomatology can independent, dependent & interdependent nrsg fnxns.
+: be illustrated in Table 1.
Consistent w/ the identified priority probs, the plan of care should be directed @:
1. Improving major organ perfusion
2. Correcting fluid imbalance @ the intravascular & interstitial compartments
Table 1: Classification of Pregnancy-Induced Hypertension (PIH) 3. Preventing fetal injury
HTN Type Symptoms 4. Managing social isolation

◘IMPLEMENTATION
While the interventions can be influenced by the identified plan of care & Dxs & the classification of a PIH, the ff are the
strategies that Ns. should expect in the care of these clients w/ this HIGH-risk pregnancy condition:
1. Bed Rest
Recumbent position for bedrest = To excrete ↑↑Na ions that have been implicated in the devt of EDEMA.
Lateral recumbent position = prevents Uterine PRESSURE &
Relieves the PRESSURE on Mother’s vena cava → preventing Supine HoTN Syndrome
✓Preeclampsia w/ SEVERE features (SEVERE Pre-eclampsia),
• @ Priv room to minimize noise & confining visitors to support Ppl only (husband/ partner, mother, older children).
= To prevent having an eclamptic episode (Ex. SEIZURE).
!! Client may be allowed to have bathroom privileges, if able.
2. Optimal Nutrition
Na restriction → may be indicated for EDEMA,
Na restriction in a PIH is found to be UNNECESSARY in Tx of clients.
Protein may be ↑d (moderate – HIGH) in the presence of ✓Proteinuria to compensate for the loss.
IV fluids may be initiated, esp. w/ SEVERE Preeclampsia as Emergency route for medications
(Ex. 💉Mg SO4, 💉Diazepam) in the event that seizure occurs.
- may also help prevent Hemoconcentration & Hypovolemia 2ndary to EDEMA formation.
NPO = Acute seizures [ASPIRATION RISK]
🖸 N. must properly regulate these fluids as the client’s fluid balance is crucial in PIH
d/t existing EDEMA & INTRAvascular fluid vol deficit.
3. Monitoring of Maternal Well-Being
The mother’s well-being can greatly influence the success of interventions. Provision of emotional support after careful
inquiry on the client’s knowledge of condition, housing & economic conditions, financial capacity, & presence of available
children @ home is necessary in order to holistically provide individualized care.
Other than emotional support, monitoring of the client’s PHYSIOLogical responses to the disease is essential.
PARAMETERS to monitor should be inclusive of:
a. BP. The N. should measure BP @ least every 4 hrs.
Frequency of checking ↑s when the client is maintained on Mg SO4 infusion as this medication can ↓ the BP.
b. BLOOD studies. Complete BLOOD count w/ PLT count, Liver enzymes, Blood urea nitrogen, & Creatinine are ordered
to evaluate Hepatic & Renal fnxn, & possible devt of disseminated intravascular coagulation
(potential complication of PIH).
c. Daily Wts. Daily monitoring of Wt @ the same time, same clothes &
Wt scale determines the client’s progress & response to Tx.
d. Urine output.
Indwelling urinary catheter is inserted to accurately monitor Urine output. Accurate documentation of I&O determines the
fluid infusion rates. Urine output per hr should be @ least 30 mL (≤ 30 mL suggest oliguria).
⛑Report to the Physician right away once urine output is recorded ≤ 30 mL.
e. Urinary proteins.
Depending on the physician’s method for urinary protein checking (Ex. Random urine sampling, 24-hour urine
collection), the N. should carefully document the degree of proteinuria as it facilitates the physician’s Dx & Evaluation of
the client’s response to Tx.
4. Monitoring of Fetal Well-Being.
Non-stress test/ Biophysical profile may be ordered to assess for uteroplacental insufficiency.
Presence of ✓fetal distress° requires maternal O2 administration.
5. Anti-Platelet Therapy.
d/t associated VASOSPASM, PLT aggregation may occur.
In line w/ this, an order for anti-platelets (Ex. 💊Baby aspirin 81mg) may be indicated.
⛑Monitoring the client while on anti-PLT therapy should be directed @ compliance to intake, &
⛑Monitoring for BLEEDING as possible adverse effects.
6. Anti-Hypertensive Therapy.
d/to the presence of ✓HTN in a PIH, anti-hypertensive medications like
💊Hydralazine (peripheral vasodilator),
💊Betalol (beta adrenergic blocker), or
💊Nifedipine (Ca channel blocker) can be ordered to ↓BP w/o interfering w/ placental circulation°
⛑Carefully monitor BP & HR as Maternal TACHYcardia & HoTN can occur.
7. Mg Sulfate (SO4) Therapy.
💉Mg SO4 = Drug of choice for clients w/ either Preeclampsia w/ HIGH RISK for Seizure/ Eclampsia
= Considered a central nervous system (CNS) depressant,
= Effective to clients w/ ↑d Neuronal irritability/ EXCITABILITY
in the case of eclampsia/ pre-eclampsia with high risk for convulsion.
= Also classified as Cathartic, by moving fluid from Cerebral cells’ interstitial spaces into the Intestine for [Excretion]
N. that administers this HIGH-RISK medication should be reminded of the ff important considerations:
i. The drug is generally given as infusion.
Initial (bolus) dose, however, can be given as a bolus, administered [IV] over a period of [15 – 30 mins]
Maintenance dose ([after] Bolus dose) is administered as a piggyback infusion.
ii. The serum therapeutic range for Mg SO4 therapy in preeclampsia ranges b/w 5 & 8 mg/100ml.
[Normal Serum Mg = 1.5 – 2.5 mEq/L]
iii. BP, Urine output, RR & Patellar reflex should be assessed B4, During & After therapy.
C/I: ↓BP, ↓Urine output (≤30ml/hr), ↓RR (≤ 12 bpm) & Hypoactive patellar reflex ( 0 or NO then do NOT give),
If ✓BURP present == DISCONTINUE infusion & notification to Physician
 iv. ↓ing sensorium/ consciousness
also requires notification to the Physician as ↑↑↑overdosing of Mg can have a profound CNS
depression.
v. Ca gluconate 10% (10 ml) administered as a slow intravenous push (SIVP) is the antidote for Mg SO4 toxicity.
🖸 A requirement for Ns. to have 💉Ca gluconate available in the unit (bedside, depending on hospital policy)
If the client is started on Mg SO4 infusion.
vi. If the client has been maintained on LONG-term Mg SO4 therapy,
Oral Ca can be continued in [post-partal period] to prevent Osteoporosis,
= A potential complication of LONG-term Mg
therapy.
8. Seizure/ Convulsion Precautions
Severe form of preeclampsia ↑s the RISK for the client to develop in Eclampsia.
Since the difference of the 2 conditions mainly relies on the ✓presence/ ABSENCE of a Seizure,
it is essential that Ns. provide seizure precautions to prevent a life-threatening eclampsia.
PRECAUTIONARY MEASURES for SEIZURE include the ff:
i. Environmental manipulation.
The room is darkened (dimmed) bc a bright light can trigger SEIZURE.
Turning the lights off then Ns. will use ◎ Flashlight for assessment = therefore triggers SEIZURE.
Shining a flashlight beam into their eyes is a form of  sudden stimulation to be
@ [12 - 24 hrs from the onset of a SEIZURE], a viable fetus° delivered via Vaginal birth w/ minimal use of Anesthesia.
Caesarian delivery may NOT be favorable d/t ↑↑HIGH Maternal BP, & ↓d INTRAvascular fluid vol 2ndary to EDEMA.
If labor induction is ineffective for Vaginal birth, however,
Caesarian birth becomes the birth method of choice bc of the imminent danger of the baby.
10. Post-partal Considerations (After Birth)
Client may continue to have 💉Mg SO4 [12 - 24 hrs after birth] to prevent Eclampsia @ this period
where the dose is tapered & is eventually discontinued.
It is also important for Ns. to include in their endorsement that
If client receives 💉Mg SO4 (especially if given [w/in 2 hrs of a baby’s birth]),
the baby may suffer SEVERE respiratory depression 2ndary to the drug’s ability to cross the placenta.
Post-partum preeclampsia may occur up to 10 - 14 days after birth (most symptoms occur w/in 48 hrs after birth).
It is therefore essential that the client is instructed to have her BP monitored @ least 2 wks in this period.
EVALUATION
Should be directed @ determining the outcomes of care w/ respect to resolution of significant clinical manifestations,
achievement of plans of care, timely & precise execution of implementation measures to alleviate/ solve identified Nrsg Dxs.

avoided.
Parameters must include but should NOT be limited to evaluation of both
ii. Restriction of visitors. Maternal (renal, cerebral, hepatic fnxns) & Fetal° (fetal heart tone, uteroplacental perfusion) fnxning.
Close family members are only allowed to visit the client as excessive stimulation triggers SEIZURE.
Provide emotional support as Social isolation is a potential concern, even if she is @ a Private room.
Client is encouraged to REST as undisturbed as possible.
iii. Minimize stress.
Client must be aware as to why necessary Tx, restriction & instructions are required of her.
Allowing herself to express concerns can help alleviate anxiety
iv. Fall precautions. Raise the side rails should a SEIZURE occur.
v. Tx measures during a seizure. The priority of care in an ECLAMPTIC SEIZURE = maintenance of a patent airway.
Measures include the ff:
▪ Report any complaints of Epigastric PAIN as it is believed to be an aura for SEIZURE.
▪ To establish airway, the client’s head is turned to the [side] to allow drainage of secretions from her mouth.
▪ As emergency measure, 💉Diazepam/ 💉Mg SO4 may be administered.
▪To protect fetal O2ation, the mother receives O2 by face mask. Monitor for O2 saturation using a pulse oximeter.
▪ Apply an External Fetal heart monitor° to determine fetal distress°.
▪ Provide extreme post ictal observation particularly assessing for vaginal BLEEDING every [15 mins] (indicative of early
placental separation) as the sensation of labor contractions may NOT be felt by the client @ this
period.

9. Intra-partal Considerations (Birth)

The decision to deliver the baby on a client w/ PIH
largely depends on the Fetal viability° (the ability of the baby to survive in the extrauterine life).
Type 2 (=) GDM
Type 1 = NOT enough insulin production
Type 2 = Insulin resistance

GDM RISKS
Family Hx of Diabetes
Age ↑45y/o
OverWt./ Obese = BMI↑30
Experience EXCESSIVE Wt. Gain [during pregnancy]
Hx of Gestational Diabetes
Asian/ Middle-Eastern Ethnicity
Fetal MACROsomia° in previous pregnancies

Diabetes Mellitus
Pathophysiological & Pregnancy
- Fetal demands
- Roles of Placental hormones
- Changes in Insulin resistance
- Effects on Mother
- Effects on Fetus [See Table 20-1]
Therapeutic management
- Preconception counseling
- Blood Gluc lvl control (HbA1C ↓7%)
Glycemic control
Nutritional management
Hypoglycemic agents
Close maternal & Fetal surveillance
Management during Labor & Birth

◘ASSESSMENT
Health Hx; Physical examination; RISK Fxs
Screening @ 1st prenatal visit; Additional screening@ 24 – 28 wks for Women considered @ RISK
Maternal surveillance: Urine for Protein, Ketones, Nitrates & Leukocyte esterase; Evaluation of Renal fnxn/ trimester; Eye exam in
1st trimester; HbA1c q 4-6 wks
Fetal surveillance: UTZ; Alpha-fetoprotein lvls; Biophysical profile; NONstress testing; Amniocentesis

NRSG MANAGEMENT
Optimal Gluc control
- BLOOD Gluc lvls; Medication therapy
- Nutritional therapy
- Measures during Labor & Birth; Postpartum
Prevention of complication
Client education & counseling
 🍏Introduction on GDM as a High-Risk Pregnancy Condition
Gestational diabetes mellitus
= Pregnancy-related type of diabetes.
= Causes ↑↑elevated BLOOD sugar lvl w/c can be detrimental to both Mother & Fetus°’ health [during Pregnancy].
Most women’s BLOOD sugar lvl remains NORMAL [during Pregnancy],
but if ↑↑BLOOD sugar lvls, they are considered to have gestational diabetes. The body’s metabolism changes [during Pregnancy].
It takes longer for sugar in the blood stream to be absorbed by the body’s cells [after a meal.] Returns to NORMAL [after Childbirth]
W/ GDM, the woman’s body has TROUBLE producing the EXTRA INSULIN needed,
thus ↑↑BS lvl than normal, while extra glucose is passed on to dvloping fetus°. About 3-5 % of pregnant women develop GDM.
Since GDM doesn’t cause any noticeable Sxs, pregnant women are often surprised to find out they have it.
They may worry about their baby’s condition & concerns that they may have diabetes [after the baby is born].
These kinds of concern can be distressing during pregnancy.
Sxs in GDM fade again [after birth] but RISK of developing type 2 diabetes maybe as high as 50%-60%.
Women w/ GDM are more likely to develop type 2 diabetes later in life.
[During Pregnancy] important hormones that are needed for the baby’s growth interferes w/ Insulin.
Insulin = hormone secreted by the Pancreas & results in ↓↓ing BS lvls in the blood stream
[In Pregnancy] the hormones that are secreted by the Placenta make the mother’s body less responsive to Insulin “Insulin resistance”
[During Pregnancy] Pancreas secretes ↑ing amt of Insulin to overcome the body’s ↑ing Insulin resistance.
The presence of ✓Estrogen, Progesterone, Cortisol, Catecholamine & Human Placental Lactogen
Block the effect on insulin (contrainsulin effect) w/c usually begins about [20-24 wks] into the pregnancy.
Blood Glucose Monitoring
More than understanding the devt of HYPERglycemia = 1 of the classic manifestations of Gestational diabetes, it is required of Ns. to become
skillful in the monitoring of blood glucose ranging from the performance of required skill, when to report such abnormal reading, what to expect
as Tx measure to combat such imbalance. In this video viewing activity, you will be able to appreciate the step-by-step instruction on how to
check blood sugar on clients that require such monitoring through this link: https://www.youtube.com/watch?v=28oRB1LWWEw&t=3s
🍏 Nursing Care Management of Clients with a GDM through the Application of the Nursing Process
APPLICATION of the NRSG PROCESS
ASSESSMENT
Approximately 2%-3% of all women who do NOT have diabetes during the [1st trimester] of pregnancy
will usually develop Diabetes @ the [Midpoint/ 2nd trimester of pregnancy]
Fxs that ↑ chances of a person in dvloping Gestational Diabetes. The ff fxs are identified:
1. OVERWt (BMI = ↑/ > 25) or OBESITY (BMI = ↑/ > 30)
2. AGE ↑/ over 25
3. Hx of the ff conditions: Large babies (10 lbs/ more), Unexplained Fetal°/ Perinatal loss°, Congenital anomalies in previous
pregnancies, Polycystic ovary syndrome, a family Hx of diabetes, HTN & a member of a population w/ a HIGH RISK for diabetes
4. Race: Asian, Native American, Hispanic
S/Sx
1. Hyperglycemia. In a woman w/ GDM insulin lvl is INSUFFICIENT, therefore the glucose canNOT be used by the body cells, & therefore
↑↑Glucose stays in the bloodstream.
S/Sxs = ↑Thirst (POLYdipsia), frequent urination (POLYuria), ↑Hunger (POLYphagia), glycosuria, confusion, weakness,
dry mouth, blurry vision, headache & nausea.
2. Glycosuria. Hormonal changes during pregnancy allow for ↑d BLOOD flow to the Kidneys
@ the same time begin to excrete quantities of the urine (Glycosuria)
3. Hypoglycemia. At the same time, the continuous use of glucose by the Fetus° may lead to ↓↓ed Glucose lvl (hypoglycaemia)
S/Sx = Sweating (diaphoresis), pallor, irritability, palpitations, Light-headedness, N/V, shaking & tingling around the mouth.
4. DHN. d/t ↑↑↑↑↑concentration of BLOOD Serum & ↓↓↓↓↓decline in blood vol (BV)
5. Macrosomia. bc Fetus° continuously receives Glucose thru Placenta.
Routine screening test for gestational diabetes is usually done on the [20- 24 wk of Pregnancy]
Consists of an initial glucose challenge test, where the woman is required to drink a 50-gram glucose solution.
[1 hr later], if Result of Glucose lvl = more than 140 milligrams per deciliter, she is scheduled for a 100-gram fasting glucose tolerance test,
then another blood sample will be taken [after 1 hr, 2 hrs, & 3 hrs respectively].
If 2 of the 4 blood samples collected are ABNORMAL,/ if the fasting value is above 95mg/dL, a Dx of gestational diabetes is made.
The other values that confirm gestational diabetes: 1 hour after fasting,180mg/dL, 2 hours 155mg/dL, & after 3 hours 140mg/dL.
2. Glycosylated hemoglobin (“A1c” “HbA1c”).
HGB = Substance in the RBCs that carries O2 to the cells of the body
Glucose = a type of sugar molecs in the BLOOD normally become stuck to HGB molecs. This means that HGB becomes GLYCOSYLATED.
Measuring glycosylated hemoglobin = advantageous since it reflects the average BLOOD Glucose lvl [over the past 2-6 wks]
3. Eye screening. Diabetic retinopathy = most common pre-existing ocular condition that may be worsened by pregnancy.
Eye examination should be done [@ each trimester]
4. Tests for Placental Function & Well Being.
Alpha-fetoprotein lvl blood test = used to check the incidence of birth anomalies & genetic disorders, done [@ 15-17 wks] of pregnancy.
5. UTZ. Performed approximately to detect Gross abnormalities & Placental changes.
6. Creatinine clearance.
This test may be ordered [each trimester]r to determine the condition of the Vascular system.
☺ NORMAL Creatinine clearance suggests a ☺ Kidney fnxn = NORMAL
Dx
IMPLEMENTATION
1. 💉Insulin injection.
If diet & exercise = NOT successful in regulating glucose values, Insulin will be required especially on the latter part of pregnancy.
Type of insulin recommended in GDM is usually short-acting insulin (Regular, Clear in consistency), combined w/ an
intermediate type (NPH, cloudy).
Regular insulin ↓↓lowers BLOOD Glucose lvl [w/in 30 mins after breakfast w/ a 1 hr peak time]
Onset of axn in NPH insulin [1-4 hrs w/ a peak of 6-10 hrs, & it‘s duration is about 10-16 hrs]
Human insulin = recommended bc it has ↓↓lesser antibody response than Beef/ Pork insulin.
2. Insulin pump therapy. The use of an insulin pump is the best assurance to keep the serum glucose constant.
Insulin pump = automatic about the size of an mp3 player attached to a woman’s Lower abdomen/ Thigh.
 3. Caesarian section. Complications of gestational diabetes like→ Preterm birth & LARGE size fetus° = indications for CS section ▪ Fetal macrosomia. EXCESSIVE Birth Wt.,
Typically weighs 9 lbs/ more makes them @ RISK for birth injuries.
Also ↑s the need for Caesarean section.
Nrsg Interventions
▪ Preterm birth. HIGH BLOOD sugar lvl may precipitate [early labor & delivery] prior to the expected delivery date.
Ns. should provide accurate & up-to-date info abt the client’s condition to come up w/ appropriate interventions & management.
1. Nrsg ASSESSMENT
▪ Serious breathing disorders like→ NB Respiratory distress syndrome w/c are common in Preterm NBs.
- Assess the client’s Hx to determine if there are RISK fxs r/t the Dx of Gestational diabetes, Lifestyle, Cultural & Economic fxs.
- Perform PHYSICAL & NEUROLOGIC EXAMINATION
▪ Hypoglycemia. Low blood sugar after birth & risk for having type 2 diabetes & obesity later in life.
- Assess for Laboratory results ( fasting/glucose tolerance test, urinalysis, serum creatinine)
- Assess for S/Sxs presented & observed
▪ Still birth/ Fetal death° [B4/ shortly after delivery]
2. Related Nrsg Dxs
o Deficient knowledge r/t therapeutic regimen necessary during pregnancy
Summary & Conclusion
o Deficient knowledge r/t complex health problems
Pregnancy Induced-Hypertension (PIH)
o Ineffective peripheral tissue perfusion r/t excessive glucose in the bloodstream
Previously referred to as the “toxemia of pregnancy”,
o Fatigue PIH = described as HTN that is acquired in pregnancy usually beginning [@ 20 wk of pregnancy] &
o Health seeking behaviour r/t verbalized need to learn home glucose monitoring may even persist [2 wks postpartum]
o Risk for infxn r/t concentration of blood serum Depending on the extent of proteinuria, EDEMA & HTN, as the classical manifestations of PIH, classification by the physician is
somewhat useful in determining the course of action & client’s prognosis.
3. Nrsg Measures Ultimately, application of nursing process is always geared towards maintenance of both Maternal & Fetal° well-being.
- Education regarding Nutrition [during Pregnancy]. Diet = ↓↓reduced amnt of saturated FATS & cholesterol & an ↑d amnt of dietary Fiber.
↑d fiber = ↓postprandial HYPERglycemia & thus ↓↓lowering insulin requirement Clinical manifestations may range from the effect of Systemic organs that include but are NOT limited to involvement of the Cerebral,
1800-2400 calorie diet is divided into 3 meals & 3 snacks is usually prescribed. Renal & Hepatic fnxns.
Of these dietary calories, 40-50% Carbohydrates, 20% = Protein, , & up to 30% fats. Plan of care is aimed @ improving organ tissue perfusion, correction of fluid balance, preventing fetal compromise & managing social
Wt. GAIN should be maintained approximately 25-30 lbs isolation. Implementation is focused on enhancing maternal cooperation w/ prescribed Tx for HTN, PLT aggregation, Seizure, Nutrition
- Education regarding exercise [during Pregnancy]. & Fetal° health. The role of the nurse in clients with PIH is critical as the client is to receive a high-risk medication in the form of Mg
Exercise = another way of ↓ing Serum Glucose lvl & thereby the need for Insulin SO4, the DOC for SEVERE Preeclampsia, other than possibility of a convulsion in Eclampsia. Precautionary measures r/t Seizure are
Low impact aerobic exercises are good for pregnant women w/ gestational diabetes like→ of equal importance as clients w/ poorly controlled preeclampsia can greatly shift to eclampsia.
walking for 30 mins, swimming, gardening, doing light household
chores Care for clients w/ PIH greatly spans the moment that manifestations arise in the course of pregnancy & continues w/ post-partal stage.
[During Exercise], Insulin = released quickly & can cause Hypoglycemia The application of Nrsg process = essential in the care of this HIGH-risk pregnancy condition.
To prevent it, the client should be instructed to eat a snack consisting of Protein/ Complex carbohydrates B4
exercising.
- Education regarding Home Glucose monitoring = determines the Serum Glucose lvl. Gestational Diabetes Mellitus (GDM)
Done by means of a ✰Finger prick technique. Diabetes mellitus = Endocrine disorder in which the pancreas cannot produce adequate Insulin to regulate body glucose lvl.
Using a Lancet, prick 1 fingertip, places a drop of blood on a test strip. The strip then is inserted into a Glucometer. The disorder affects 3-5% of ALL pregnancies & is the most frequently seen medical condition. .
- Review fxs in Glucose instability. The incidence of Type 2 diabetes in adolescents has ↑d dramatically in the last decade r/t Obesity
Review client’s common situations that contribute to glucose instability like→ Missing a meal, infxn & other illnesses. Gestational diabetes affects the systemic circulation thus presenting various S/Sxs.
- Discuss how client’s anti-diabetic medication work. Medical & Nrsg managements = geared towards maintaining the serum blood glucose to be able to prevent occurrence of other disorders.
Educate the client on the fnxns of her medications bc there are combinations of drugs that work in different ways. Early screening, Dx & management of gestational diabetes are important to prevent/ reduce complications during & post-pregnancy for
- Check 💉Injection site periodically. Insulin absorption can vary day to day in healthy sites & is less absorbable in Lipohypertrophic tissues. both the mother & the baby.
- Educate client about the need for REST until condition is stable.
- Encourage client to assume a recumbent position to prevent SHS→ Supine HoTN Sydrome
- Monitor fetal well-being°.
- The N. should watch out for possible maternal complications such as:
▪ HTN. ↑↑BLOOD sugar can lead to an serious complication like→ Preeclampsia that may put the mother & the baby’s° life @ RISK
▪ POLYhydramnios
▪ Delivery via C-Section. Macrosomia can cause the baby to become wedged in the birth canal causing difficulty in Vaginal delivery.
▪ Diabetes. It can either developed on the succeeding pregnancy/ later in life.
- Similarly, the N. should also monitor the baby° for possible complications such as: