Which of the following is the best next step for a patient with gestational diabetes whose home glucose levels are poorly controlled?

The appropriate next step for a patient with gestational diabetes who is experiencing poorly controlled home glucose levels is to start insulin therapy, which is represented by the option to start both long-acting and short-acting insulin.

In cases of gestational diabetes where dietary modifications and exercise have proven inadequate in achieving target glucose levels, insulin therapy becomes essential. Insulin is effective in reducing blood glucose levels and can be adjusted based on the patient's individual needs, ensuring better glycemic control. Long-acting insulin helps manage baseline glucose levels, while short-acting insulin can be utilized for addressing postprandial spikes in glucose after meals.

Choosing to initiate only dietary modifications or encouraging more exercise may not be sufficient for a patient already struggling with glucose control. Additionally, while metformin is occasionally used for gestational diabetes, insulin remains the first-line treatment due to its effectiveness in quickly lowering blood sugar levels and its safety profile in pregnancy. Other options like changing medication for hypertension are not directly relevant to managing gestational diabetes and would not address the current problem of poor glucose control.