A nurse is caring for a 16-year-old primigravida who is in the last month of an uncomplicated pregnancy.
Which measure is most appropriate to include in the patient’s plan of care?
Remind her that an increase in fetal activity will require an increase in her need to rest.
Explain to her that she is likely to have back labor.
Arrange for her to meet the staff who will be caring for her during labor and delivery.
Teach her how to test her urine for the presence of glucose.
The Correct Answer is C
The correct answer is choice C. Arrange for her to meet the staff who will be caring for her during labor and delivery. This measure can help reduce the anxiety and fear of the unknown that a primigravida may have in the last month of pregnancy. Meeting the staff can also help establish rapport and trust, which are essential for a positive birth experience.
Choice A is wrong because an increase in fetal activity does not necessarily require an increase in the need to rest.
Fetal activity is normal and expected, and the mother should monitor it regularly. Resting may help with some discomforts of pregnancy, but it is not directly related to fetal activity.
Choice B is wrong because back labor is not likely for a primigravida with an uncomplicated pregnancy.
Back labor occurs when the fetus is in an occiput posterior position, which puts pressure on the mother’s spine and causes intense pain in the lower back. This position is more common in multiparous women than primigravidas.
Choice D is wrong because testing urine for glucose is not a routine measure for a primigravida with an uncomplicated pregnancy.
Urine glucose testing is done for women who have gestational diabetes or are at risk of developing it. It is not necessary for women who have normal blood glucose levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. Dry off the newborn.This is the priority nursing action because it prevents heat loss and hypothermia in the newborn.
The newborn has a large surface area and a thin layer of subcutaneous fat, making it vulnerable to cold stress.Drying off the newborn also stimulates breathing and crying, which helps clear the airways.
Choice A is wrong because obtaining a serum sample is not a priority action and may cause unnecessary pain and bleeding in the newborn.
Choice C is wrong because assessing the newborn’s Moro reflex is not a priority action and may be done later during the physical examination.Choice D is wrong because obtaining the newborn’s footprints is not a priority action and may be done after the bonding and breastfeeding period.
Correct Answer is D
Explanation
The correct answer is choice D. Decreased respirations.Magnesium sulfate is a medication that can causerespiratory depression, which means it can slow down or stop breathing.
This is a serious side effect that needs to be monitored closely by the nurse.
Choice A is wrong because increased Babinski reflex is not a side effect of magnesium sulfate.
The Babinski reflex is a normal response in infants, but abnormal in adults.
It occurs when the big toe bends upward and the other toes fan out when the sole of the foot is stroked.Magnesium sulfate can causepoor reflexes, but not specifically the Babinski reflex.
Choice B is wrong because diarrhea is not a side effect of magnesium sulfate when given intravenously or intramuscularly.Diarrhea can occur when magnesium sulfate is taken orally as a laxative, but that is not the case in this question.
Choice C is wrong because tetany is not a side effect of magnesium sulfate.
Tetany is a condition that causes muscle spasms and cramps due to low levels of calcium in the blood.Magnesium sulfate can actually causehypocalcemia, which means low levels of calcium in the blood, but this does not usually result in tetany.Tetany is more likely to occur when there is low magnesium in the blood, which is calledhypomagnesemia.
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