A nurse is assessing a pregnant client at 32 weeks gestation with gestational diabetes mellitus (GDM). Which assessment finding would be most concerning and require immediate intervention?
1Fasting blood glucose level of 110 mg/dL
2Fundal height measuring 38 cm at 32 weeks gestation✓ 정답
3Mild pedal edema in both feet
4Weight gain of 2 pounds in the past 2 weeks
해설
Fundal height of 38 cm at 32 weeks indicates macrosomia, a serious complication of GDM requiring immediate intervention for risks like shoulder dystocia. Other findings (elevated glucose, mild edema, weight gain) are less urgent and manageable with routine monitoring.
Core Nursing ExplanationKey Concept Analysis: This question assesses the ability to identify a critical complication of gestational diabetes mellitus (GDM) that requires immediate nursing action. GDM increases the risk of fetal macrosomia (excessive fetal growth), which can lead to dangerous delivery complications. The key assessment tool for detecting potential macrosomia is fundal height measurement, which should correlate closely with gestational age in weeks (±2 cm).
Answer Rationale: Key Point! A fundal height of 38 cm at 32 weeks gestation is significantly greater than the expected range of 30-34 cm. This discrepancy of +6 cm is a strong clinical indicator of macrosomia or polyhydramnios (excess amniotic fluid), both associated with poorly controlled GDM. This finding is most concerning because it signals an immediate need for further evaluation (e.g., ultrasound) and possible intervention to plan for a safe delivery and prevent emergencies like shoulder dystocia.
Distractor Analysis:
Watch out for confusion! A fasting blood glucose of 110 mg/dL is elevated (target is typically <95 mg/dL for GDM) and requires management, but it is a chronic finding that guides dietary or medication adjustments, not an immediate physical danger requiring urgent intervention at that moment.
Correct. The significant fundal height discrepancy is a direct, physical sign of a potentially dangerous fetal complication.
Mild, bilateral pedal edema is a common finding in the third trimester due to increased venous pressure and is not specific to GDM. It becomes concerning only if it is sudden, severe, or accompanied by hypertension and proteinuria (signs of preeclampsia).
A weight gain of 2 lbs in 2 weeks is within the recommended guidelines for the third trimester (approx. 1 lb/week) and is not an alarming finding by itself.
Related Concepts: This integrates knowledge of antepartum assessment, diabetes in pregnancy, and priority-setting. The nurse must differentiate between expected pregnancy variations, chronic disease markers, and signs of acute fetal compromise.
Concept Summary
Concept
Key Takeaway
Gestational Diabetes Mellitus (GDM)
Glucose intolerance first recognized in pregnancy. Major fetal risk is macrosomia.
Fundal Height (McDonald's Rule)
Should equal gestational age in weeks (±2 cm). A large discrepancy (>3 cm) warrants investigation.
Macrosomia
Fetal weight >4000-4500g. Increases risk of shoulder dystocia, birth trauma, and cesarean section.
Nursing Priority
Findings indicating immediate threat to mother or fetus (like signs of macrosomia leading to dystocia) take precedence over abnormal but stable lab values.
Side-by-Side Comparison!
Assessment Finding in 3rd Trimester
Typical / Expected
Concerning / Requires Action
Fundal Height
Within 2 cm of gestational age in weeks.
Consistently >3 cm above or below dates.
Pedal Edema
Mild, bilateral, worse at end of day.
Sudden onset, severe, facial/hand edema, with hypertension.
Weight Gain
~1 lb (0.5 kg) per week in 2nd/3rd trimester.
Sudden gain >2 lbs/week, may indicate fluid retention.
Fasting Glucose (GDM)
<95 mg/dL
Persistently >95 mg/dL; requires therapy adjustment but not "immediate intervention" unless acutely hyperglycemic with ketosis.
Anatomy, Physiology & Pharmacology Points
Pathophysiology: Maternal hyperglycemia → fetal hyperglycemia → fetal pancreas secretes excess insulin → insulin acts as a growth hormone → promotes excessive fetal growth (macrosomia) and fat deposition.
Measurement: Fundal height is measured from the symphysis pubis to the top of the uterine fundus. It estimates fetal growth and amniotic fluid volume.
Pharmacology Link: Management of GDM may include insulin (e.g., NPH, Regular) or oral agents like glyburide. Tight glycemic control is the goal to prevent macrosomia.
Memory Tips
McDonald's Rule: "Fundal height in cm ≈ Weeks of pregnancy." Think: "McDonald's serves meals by the week."
GDM Fetal Risks: Remember the acronym BIG baby: Birth trauma, Insulin issues (neonatal hypoglycemia), Growth (macrosomia).
Priority: "Physical signs of danger (like a too-big uterus) beat a lab value on paper."
High-Frequency NCLEX Topics
This question tests maternal assessment and priority-setting, two core NCLEX competencies. You will often be asked to choose the "most concerning" finding or the "priority intervention" for a client with a chronic condition (like GDM) who is showing new signs. Always look for data indicating an acute change or immediate risk to the mother or fetus.
Watch Out for Question Variations!
Shift from Assessment to Intervention: "The nurse notes a fundal height of 38 cm at 32 weeks. Which action should the nurse take first?" (Answer: Notify the healthcare provider and prepare for an ultrasound).
Shift to Postpartum/Newborn Care: "A newborn delivered to a mother with GDM is at highest risk for which complication?" (Answer: Hypoglycemia).
Combine with Other Complications: The question could add preeclampsia symptoms (e.g., hypertension + proteinuria + edema), making the priority decision more complex.
Nursing Clinical Practice GuideClinical Scenario: You are a nurse in an antenatal clinic. Maria, a 32-year-old G2P1 at 32 weeks gestation with diet-controlled GDM, comes for a routine check-up. She reports her diet has been "okay." During your assessment, you measure her fundal height.
Nursing Intervention Strategy:
Assessment:
Confirm measurement technique: Use a non-stretchable tape measure from symphysis pubis to top of fundus. Ensure bladder is empty.
Re-measure to verify the 38 cm finding.
Perform a full assessment: Check for other signs of polyhydramnios (tight, shiny abdomen, difficulty breathing), assess fetal heart rate pattern, and review glucose logs.
Immediate Action & Communication:
This is a "red flag." Immediately inform the obstetrician or midwife.
Document the finding accurately: "Fundal height 38 cm, 6 cm > expected for 32 weeks gestation. Provider notified."
Collaborative Planning:
Anticipate orders for a growth ultrasound to estimate fetal weight and assess amniotic fluid index (AFI).
Prepare for a discussion about intensifying glycemic control (may need to start insulin) and delivery planning (possible induction at 38-39 weeks or planned C-section if estimated fetal weight is very large).
Patient Education & Support:
Explain the finding to Maria in a calm, non-alarming manner: "Your uterus is measuring a bit larger than we typically see at this stage. The doctor has ordered an ultrasound to get a better look at the baby's size and fluid levels. This is a common step when you have gestational diabetes."
Reinforce strict adherence to her diabetic diet and self-monitoring of blood glucose.
Educate on signs of labor and when to call, as large babies can sometimes come early.
Patient Safety and Precautions:
Never dismiss a significant fundal height discrepancy. It is a crucial, non-invasive screening tool for fetal well-being.
In clients with GDM, always correlate fundal height with glycemic control. Poor control often manifests as accelerated growth.
During delivery of a suspected macrosomic infant, anticipate the need for additional personnel (pediatrician, extra nurses) and equipment for potential shoulder dystocia management.
Nursing Procedure & Medication FlowProcedure: Fundal Height Measurement
1. Position client supine with a pillow under head and knees slightly flexed.
2. Palpate to identify the superior border of the symphysis pubis and the top of the uterine fundus.
3. Place the "zero" end of the tape at the top of the symphysis pubis.
4. Gently stretch the tape over the contour of the abdomen to the top of the fundus.
5. Record the measurement in cm. Document any notable findings (e.g., fetal position, tenderness).
Medication (if insulin is initiated):
- Common regimen: NPH insulin at bedtime to control fasting glucose, possibly with mealtime Regular insulin.
- Critical Teaching: Teach signs of hypoglycemia (shakiness, sweating, confusion), its management (15g fast-acting carbohydrate), and the importance of consistent meal timing with insulin administration.
A Word from Your Senior Nurse
"Trust your hands and your measurements! In obstetrics, we don't have X-ray vision, so fundal height is one of our most valuable, simple tools to 'see' how the baby is growing. When you find a discrepancy like this, you're not just recording a number—you're potentially uncovering a risk that could change the entire birth plan and keep mom and baby safe. On the NCLEX and in practice, always think: 'What does this finding mean for the immediate safety of my patient?' That clinical judgment is what makes a great nurse."