A nurse in the prenatal clinic is reinforcing teaching to a client who is in her second trimester and has a new diagnosis of gestational diabetes. Which statement by the client indicates a need for further teaching?

The nurse's first action should be to massage the client's fundus, as this can help stimulate uterine contraction and prevent hemorrhage. The fundus is the upper part of the uterus that contracts and involutes after delivery to compress the blood vessels and stop bleeding. The nurse should palpate the fundus for firmness, height, and position, and massage it gently if it is boggy or displaced.

The other actions are not the first priority and may be done after massaging the fundus.

The nurse should observe for the pooling of blood under the buttocks, as this can indicate a large amount of blood loss that may not be visible on the perineal pad. However, this is not the first action to take, as it does not address the cause of the bleeding or stop it from continuing.

The nurse should assess the client's blood pressure, as this can indicate the severity of blood loss and the presence of shock. However, blood pressure may not change significantly until a large amount of blood is lost, and it is not specific to the cause of bleeding. Therefore, blood pressure is not the first action to take.

The nurse should prepare to administer a prescribed oxytocic preparation, such as oxytocin or methylergonovine, as this can enhance uterine contraction and reduce bleeding. However, this requires a provider's order and may take time to obtain and administer. Therefore, an oxytocic preparation is not the first action to take.

b. Eat foods fortified with folic acid.

Folic acid is a B vitamin that is essential for the development of the neural tube, which forms the brain and spinal cord of the fetus. A deficiency of folic acid can lead to neural tube defects such as spina bifida and anencephaly, which can cause serious complications or death for the newborn. Therefore, it is recommended that women who are planning to conceive or are pregnant consume at least 400 mcg of folic acid daily from supplements or foods fortified with folic acid, such as cereals, breads, and pasta.

The incorrect options are:

a. Increase intake of iron. Iron is a mineral that is important for the production of red blood cells and the prevention of anemia in pregnant women. However, iron deficiency does not cause neural tube defects. Iron supplements may be recommended for pregnant women who have low iron levels, but they do not affect the risk of neural tube defects².

c. Avoid the use of aspirin. Aspirin is a type of nonsteroidal anti-inflammatory drug (NSAID) that can have harmful effects on the fetus if taken during pregnancy, especially in the second and third trimesters. Aspirin can cause kidney problems, bleeding problems, premature closure of a blood vessel in the fetal heart, and increased risk of pregnancy loss¹. However, aspirin does not cause neural tube defects. Low-dose aspirin may be prescribed for some pregnant women who have certain medical conditions that increase the risk of preeclampsia or blood clots, but only under the guidance of a health care provider¹.

d. Limit consumption of alcohol. Alcohol is a known teratogen that can cause a range of physical, mental, and behavioral problems in the fetus, collectively known as fetal alcohol spectrum disorders (FASD). Alcohol can interfere with the development of the brain and other organs, and cause facial abnormalities, growth problems, learning difficulties, and behavioral issues³. However, alcohol does not cause neural tube defects. There is no safe amount or type of alcohol to drink during pregnancy, and abstaining from alcohol is the best way to prevent FASD³.