Answers to questions

33 yr old G2P1 patient arrives to L&D. She is currently 34 weeks gestation. Normal prenatal labs, including a 1 hr glucose tolerance test at 28 weeks that was 102. She is here on L&D for an elevated BP in the office, as well as proteinuria. Her prenatal records do not have the most recent visits noted on them (records were sent from the office at about 32 weeks).

1. Upon patient arrival, what should the nurse do:

a. Place patient on EFM
b. Get a BP reading in the sitting position
c. Have patient give a urine specimen for protein and glucose dip
d. All of the above

All three items are a MUST for this patient!

2. The patient is noted to be of a higher BMI (45). What type of BP cuff should be used?

a. Regular cuff
b. Large cuff
c. It doesn't matter

To get the most accurate BP reading, you need to have an appropriate size cuff, as well as proper placement on the arm. When in doubt, measure the widest part of the upper arm in centimeters, and use the cuff that fits in that measurement range. If the cuff is too small, it will register a BP that is falsely high.


3. What is the best position for taking an initial BP on a pregnant woman?

a. Lying on her left lateral side
b. Sitting upright
c. It doesn't matter

A true and accurate blood pressure reading is taken with the woman in the sitting position, with the cuff at about the level of the heart. Her arm should be at rest, or supported, so that she is not holding her arm up (which can falsely elevate the BP). Lying on her side provides the optimal blood flow to the uterus, and displaces the uterus off of the great vessels running medial in her chest/abdomen. This lowers the BP, but does not provide for a true and accurate BP reading.


4. Her BP is 162/102. What should the nurse do next?

a. Have her lay on her left or right side and recheck the BP in 5-10 minutes
b. Recheck the BP immediately, in the same position
c. Nothing

Her BP is concerning, so it must be rechecked. Some people might stop at the first reading, or immediately recheck it in the same position. However, we want to find out if the BP will decrease with her lying in a more optimal position for uteroplacental circulation for the fetus.


5. Upon performing a protein/glucose urine dip, the nurse finds the following results: Protein +2, Glucose 2000+. What should she do next?

a. Ask the patient about any s/s of preeclampsia: HA, n/v, epigastric pain, recent changes in vision, presence of edema, recent weight gain.
b. Perform a physical exam, including lung sounds and deep tendon reflexes.
c. Nothing, just notify the physician.
d. Both A and B

Both are important. The nurse needs to assess for signs and symptoms of preeclampsia that the patient might be exhibiting, as well as documentation of a thorough physical exam. The nurse will need to have a baseline of the physical exam results, in case the patient begins to show worsening symptoms of preeclampsia. Deep tendon reflexes will show whether or not the patient is showing signs of hyperreflexia - potentially worsening preeclampsia that could lead to eclampsia.


6. What, if anything, should the nurse do about the high glucose reading on the urine dip?

a. Nothing, it's probably a mistake since she passed her one hour glucose tolerance test.
b. Tell the patient she is diabetic.
c. Perform a bedside glucose fingerstick to find out the blood glucose level.

A follow up on the abnormal urine glucose results are a must. The physician/midwife will also want to know what the fingerstick glucose result is, so it is important to have that information handy. While the patient is more than likely diabetic, it is not in the nurse's scope of practice to make a medical diagnosis. She can, however, educate the patient on the possible reasons why she is spilling glucose into her urine.

7. What type of lab work would the nurse expect the physician/midwife to order for this patient?

a. Nothing, send her home. Have her follow up in two days in the office.
b. Preeclampsia labs (uric acid, creatinine, CBC with diff, ALT/AST, start a 24 hour urine for protein).
c. Hemoglobin A1C.
d. Both B and C

Self explanatory. With the high blood pressure, the proteinuria, and the glucosuria, it needs to be further investigated as to whether the patient is preeclamptic and/or gestational diabetic. While the HgbA1C will not determine if the patient has gestational diabetes, it will give a quick view of what her average blood glucose range has been for the past three months. A definitive test for GDM is the 3 hour glucose tolerance test. Or, at this late gestation, a diagnostic test may not be ordered, but regular blood glucose levels and a diabetic diet would be prescribed for the remainder of the pregnancy.