# 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?

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> language: ko  
> subject: Maternal Newborn Health

## 문제

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?

## 보기

1. Fasting blood glucose level of 110 mg/dL
2. Fundal height measuring 38 cm at 32 weeks gestation **✔ 정답**
3. Mild pedal edema in both feet
4. Weight gain of 2 pounds in the past 2 weeks

**정답: 2**

## 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.

## 심화 해설

Understanding the Clinical Context

At 32 weeks gestation, a client with gestational diabetes mellitus (GDM) requires vigilant monitoring because maternal hyperglycemia drives fetal hyperinsulinemia, which in turn acts as a potent growth factor. The most concerning assessment finding is the one that signals poor glycemic control leading to a significant fetal complication.

Analysis of the Most Concerning Finding

A fundal height measuring 38 cm at 32 weeks gestation is the finding that requires immediate intervention. Fundal height in centimeters typically correlates with gestational age in weeks between 20 and 36 weeks, with a normal variance of ±2 to 3 cm. A measurement of 38 cm at 32 weeks is significantly discordant, suggesting a larger-than-expected uterine size. In a client with GDM, this clinical sign is a strong indicator of fetal macrosomia or a large-for-gestational-age (LGA) fetus, often accompanied by polyhydramnios (excess amniotic fluid). Both conditions are direct consequences of suboptimal maternal glucose control. This finding demands immediate assessment, which may include an ultrasound for fetal biometry and amniotic fluid index, and a thorough review of the client's glycemic log and management plan to prevent further complications like shoulder dystocia, birth trauma, or worsening metabolic instability [2].

Why the Other Options Are Less Critical

1.  Fasting blood glucose level of 110 mg/dL: While this value is above the typical target for GDM (usually

## 임상 시나리오

Clinical Scenario

A 32-week pregnant client with GDM presents for a routine antepartum visit. Fundal height measures 38 cm, significantly exceeding the expected 30-34 cm range. The nurse prioritizes this finding as it strongly suggests fetal macrosomia or polyhydramnios, both consequences of poor glycemic control.

Assessment & Intervention

- Perform an immediate ultrasound to assess fetal biometry (estimated fetal weight, abdominal circumference) and amniotic fluid index (AFI).

- Review the client's blood glucose log for patterns of hyperglycemia and reinforce strict dietary adherence, physical activity, and medication compliance.

- Assess for signs of preterm labor or respiratory compromise, as polyhydramnios can cause uterine overdistension and maternal dyspnea.

- Notify the obstetric provider promptly and prepare for possible adjustments in the plan of care, including increased fetal surveillance (non-stress tests, biophysical profiles) or early delivery planning to mitigate risks of shoulder dystocia and birth trauma.

Clinical Pearls

- Fundal height >3 cm above gestational age warrants immediate investigation; in GDM, macrosomia is the primary concern.

- Maternal hyperglycemia leads to fetal hyperinsulinemia, which acts as a growth factor, especially affecting the fetal shoulders and abdomen.

- Isolated mild pedal edema and steady weight gain are normal third-trimester findings and do not take priority over a discordant fundal height.

## 핵심 개념

- **Fundal Height Discordance** — A discrepancy where the fundal height in centimeters exceeds the gestational age in weeks by more than 2-3 cm, often indicating fetal macrosomia, multiple gestation, or polyhydramnios.
- **Fetal Macrosomia** — A condition where a newborn has an excessive birth weight, often defined as over 4000-4500 grams, commonly resulting from maternal hyperglycemia driving fetal hyperinsulinemia and overgrowth.
- **Polyhydramnios** — An excessive accumulation of amniotic fluid, which can be a complication of GDM due to fetal polyuria caused by maternal hyperglycemia.

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