Question 1

A woman tells a primary care NP that she is considering getting pregnant.During a health history,the NP learns that the patient has seasonal allergies,asthma,and epilepsy,all of which are well controlled with a second-generation antihistamine daily,an inhaled steroid daily with albuterol as needed,and an antiepileptic medication daily.The NP should counsel this patient to:

A) take her asthma medications only when she is having an acute exacerbation.
B) avoid using antihistamine medications during her first trimester of pregnancy.
C) discontinue her seizure medications at least 6 months before becoming pregnant.
D) use only oral corticosteroids and not inhaled steroids while pregnant for improved asthma control.

Accepted Answer

Optimal treatment of asthma during pregnancy includes treatment of comorbid allergic rhinitis,which can trigger symptoms.Antihistamines are recommended after the first trimester,if possible.Asthma medications should be continued during pregnancy because poorly controlled asthma can be detrimental to the fetus; she should continue using her daily inhaled corticosteroid.Although discontinuing seizure medications is optimal,this must be done in conjunction with this woman's neurologist because management of epilepsy during pregnancy is beyond the scope of the primary care provider.Oral corticosteroids have greater systemic side effects and greater effects on the fetus and should be used only as necessary.

Question 2

A woman has just learned she is pregnant and is in her 10th gestational week.The woman reports that she takes valproic sodium (Depakote)for a seizure disorder and has been seizure-free for several years.The NP should:

A) prescribe folic acid supplements.
B) change her antiepileptic drug to lamotrigine (Lamictal).
C) order prophylactic vitamin K to be given in the second trimester.
D) recommend that she discontinue taking the valproic sodium by 12 weeks.

Accepted Answer

Maternal folic acid deficiency is induced by anticonvulsants,especially valproic acid,so folic acid supplements must be given.Although antiepileptic drugs can have consequences for the developing fetus,once a woman is pregnant,the benefit-risk ratio favors continued use of the woman's current antiepileptic medication,so she should not discontinue the medication or change to lamotrigine.Vitamin K is recommended beginning at 36 weeks of gestation and for the newborn at birth to counter the possibility of hemorrhagic disease of the newborn.

Question 3

A woman who is pregnant tells an NP that she has been taking sertraline for depression for several years but is worried about the effects of this drug on her fetus.The NP will consult with this patient's psychiatrist and will recommend that she:

A) stop taking the sertraline now.
B) continue taking the antidepressant.
C) change to a monoamine oxidase inhibitor (MAOI).
D) discontinue the sertraline a week before delivery.

Accepted Answer

Many women are taking medication for depression before becoming pregnant.Abrupt discontinuation is not recommended,and many clinicians suggest that women at high risk for serious depression during pregnancy might best be served by continuing medication throughout pregnancy.MAOIs may limit fetal growth and are generally discouraged during pregnancy.It is not necessary to discontinue the sertraline just before delivery.

Question 4

A woman is in the 36th week of pregnancy.The nurse practitioner (NP)providing prenatal care learns that the woman has a history of two previous urinary tract infections during this pregnancy.A dipstick urinalysis in the office today is negative for leukocyte esterase and nitrites.The NP should:

A) prescribe a low-dose sulfonamide antibiotic for urinary tract infection prophylaxis.
B) order nitrofurantoin daily to minimize the patient's risk of urinary tract infection late in her pregnancy.
C) encourage the patient to increase daily water intake and to wear only cotton underwear.
D) order a voiding cystourethrogram to rule out structural anomalies that may cause urinary tract infection.

Accepted Answer

For women at risk for recurrent urinary tract infection while pregnant,prevention and treatment begin with nonpharmacologic therapy: forcing fluids and wearing cotton underpants.Sulfonamide antibiotics and nitrofurantoin are used for documented urinary tract infection during pregnancy,but not after the 36th week of gestation.A voiding cystourethrogram is not indicated and would expose the fetus to radiation.

Question 5

A woman who is pregnant develops gestational diabetes.The NP's initial action is to:&#10;A) prescribe an oral antidiabetic agent.&#10;B) give her information about diet and exercise.&#10;C) begin treating her with daily insulin injections.&#10;D) reassure her that her glucose levels will return to normal after pregnancy.

Accepted Answer

Patients with gestational diabetes should be treated with diet and exercise,with insulin added as needed for poor control.There is insufficient evidence to support the use of oral antidiabetic agents during pregnancy,and some of these are pregnancy category D.Insulin injections may be used but are not the initial intervention.Although glucose levels will return to prepregnancy values in the postpartum period,the NP must initiate therapy.

Question 6

A woman who takes an angiotensin converting enzyme inhibitor for hypertension tells her primary care NP that she is trying to get pregnant.The NP should:&#10;A) consider replacing her angiotensin converting enzyme inhibitor with methyldopa.&#10;B) lower her angiotensin converting enzyme inhibitor dose during the first trimester.&#10;C) counsel her to increase her antihypertensive medications during pregnancy.&#10;D) add an angiotensin receptor blocker (ARB) during the first trimester of her pregnancy.

Accepted Answer

Angiotensin converting enzyme inhibitors,ARBs,and statins are contraindicated during the first trimester of pregnancy and should be discontinued before conception and replaced by safer alternatives,such as methyldopa.The use of antihypertensives during pregnancy remains controversial; increasing the dose is not indicated.

Question 7

A woman is 4 weeks pregnant.The primary care NP sees her for her first prenatal visit and obtains a rubella titer,which is negative.The woman tells the NP that she drinks 2 cups of coffee and smokes 3 to 5 cigarettes each day.She denies alcohol use.The NP should:

A) administer rubella vaccine.
B) provide smoking cessation information.
C) counsel her to avoid caffeine while pregnant.
D) reassure her that her habits are not likely to cause harm.

Accepted Answer

Each cigarette smoked decreases maternal blood pressure for up to 15 minutes and decreases uteroplacental perfusion.The NP should encourage the woman to quit smoking.Rubella vaccine should be given after the baby is delivered because rubella vaccine is a live virus,with severe teratogenic effects.There is no conclusive evidence that women who are pregnant should avoid caffeine completely.Her habits,although not severe,are not harmless.

Question 8

A woman who is breastfeeding her infant asks the primary care NP what she can use for headaches while she is nursing.The NP tells her:&#10;A) most medications enter breast milk and are not safe.&#10;B) most over-the-counter medications are safe for the breastfed infant.&#10;C) she may need to interrupt breastfeeding when taking headache medications.&#10;D) she should consider weaning her infant to formula if her headaches are frequent.

Accepted Answer

Most over-the-counter medications are considered safe for the breastfed infant and do not necessitate a disruption of breastfeeding,even though most medications cross easily into breast milk.Any interruption of breastfeeding carries a risk of premature weaning and so is indicated only when the mother must take medications known to cause serious harm to the baby.It is not recommended that she wean her infant to formula when she needs medications for her headaches.

Deck 6: Special Populations: Pregnant and Nursing Women