An adolescent patient at 20 weeks gestation states that it is important not to have a baby that weighs too much. She states this has been her rationale for limiting calories. Her weight has decreased from 110 pounds to 106 pounds.
What would be the best nursing response? Select one:

Choice A Reason: Rule out a suspected hydatidiform mole. This is an incorrect answer that describes an unlikely condition for this client. A hydatidiform mole is a type of gestational trophoblastic disease where abnormal placental tissue develops instead of a normal fetus. A hydatidiform mole can cause vaginal bleeding, hyperemesis gravidarum (severe nausea and vomiting), preeclampsia, and hyperthyroidism. A hydatidiform mole usually causes a fundal height measurement that is larger than expected for gestational age, not smaller.

Choice B Reason: Assess for congenital anomalies. This is an incorrect answer that implies that the client has not had a previous ultrasound to screen for fetal anomalies. Congenital anomalies are structural or functional defects that are present at birth, such as cleft lip, spina bifida, or Down syndrome. Ultrasound can detect some congenital anomalies by visualizing the fetal anatomy and morphology. However, ultrasound screening for fetal anomalies is usually done between 18 and 22 weeks of gestation, not at 32 weeks.

Choice C Reason: Determine fetal presentation. This is an incorrect answer that suggests that the client has an uncertain fetal presentation. Fetal presentation is the part of the fetus that is closest to the cervix, such as vertex (head), breech (butocks or feet), or transverse (shoulder). Fetal presentation can affect the mode and outcome of delivery. Ultrasound can determine fetal presentation by locating the fetal head and spine. However, fetal presentation can also be assessed by abdominal palpation or vaginal examination, which are simpler and less invasive methods.

Choice D Reason: Monitor fetal growth. This is because fundal height measurement is a method of estimating fetal size and gestational age by measuring the distance from the pubic symphysis to the top of the uterus (fundus) in centimeters. A fundal height measurement that is significantly smaller or larger than expected for gestational age may indicate intrauterine growth restriction (IUGR) or macrosomia, respectively. IUGR means that the fetal growth is slower than expected for gestational age, which can increase the risk of fetal distress, hypoxia, acidosis, and stillbirth. Macrosomia means that the fetal weight is higher than expected for gestational age, which can increase the risk of birth injuries, shoulder dystocia, cesarean delivery, and hypoglycemia. Ultrasound is a more accurate way of assessing fetal size and growth by measuring various parameters such as biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), and femur length (FL). Ultrasound can also detect other factors that may affect fetal growth such as placental function, amniotic fluid volume, umbilical cord blood flow, and fetal anomalies.

Choice A Reason: Insulin needs decrease in the first trimester, but increase in the second trimester as the woman's body becomes more insulin-resistant. This is because this statement describes the typical patern of insulin requirements during pregnancy for women with pre-existing diabetes. Insulin needs decrease in the first trimester due to increased insulin production by the pancreas, increased insulin sensitivity by the tissues, and increased risk of hypoglycemia due to nausea and vomiting. Insulin needs increase in the second trimester due to increased levels of placental hormones such as human placental lactogen (hPL), which antagonize insulin action and cause insulin resistance.

Choice B Reason: Vascular disease that always accompanies diabetes slows fetal growth. This is an incorrect answer that makes a false and exaggerated claim about diabetes and fetal growth. Vascular disease does not always accompany diabetes, but it can be a complication of long-term or poorly controlled diabetes that affects blood vessels and circulation. Vascular disease can affect fetal growth by reducing placental perfusion and oxygen delivery, but it is not the only factor that influences fetal growth. Other factors include maternal nutrition, genetics, infections, or anomalies.

Choice C Reason: The risk of ketoacidosis decreases during the length of the pregnancy. This is an incorrect answer that contradicts the evidence and guidelines on diabetes and ketoacidosis during pregnancy. Ketoacidosis is a metabolic emergency where high levels of ketones accumulate in the blood due to insufficient insulin or excessive glucose utilization, which causes acidosis, dehydration, electrolyte imbalance, and coma. Ketoacidosis can occur in women with diabetes during pregnancy due to infection, stress, starvation, or inadequate insulin therapy. The risk of ketoacidosis does not decrease during the length of the pregnancy, but rather increases in the second and third trimesters due to increased insulin resistance and glucose production.

Choice D Reason: The baby is likely to have a congenital abnormality because of the uncontrolled diabetes. This is an incorrect answer that implies a negative and deterministic outcome for the baby. Congenital abnormalities are structural or functional defects that are present at birth, which can affect various organs or systems in the baby.

Congenital abnormalities can be caused by genetic or environmental factors, or a combination of both. Diabetes can increase the risk of congenital abnormalities, especially if the blood glucose levels are high during the first trimester, when organogenesis occurs. However, the risk of congenital abnormalities is not inevitable or predictable, and it can be reduced by maintaining good glycemic control before and during pregnancy.