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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

he correct answer is choice D. Keep the infant well hydrated.This is because phototherapy can cause dehydration due to increased insensible water loss from the skin.Hydration helps the infant excrete bilirubin in urine and stool.

Choice A is wrong because elevating the head of the infant’s crib does not affect bilirubin levels or phototherapy effectiveness.

Choice B is wrong because applying a water-soluble ointment to the infant’s eyes can interfere with eye protection and cause eye irritation.The infant’s eyes should be covered with opaque patches or goggles during phototherapy to prevent eye damage.

Choice C is wrong because dressing the infant in a long-sleeved shirt reduces the amount of skin exposed to light and decreases the efficacy of phototherapy.The infant should be undressed except for a diaper and eye protection during phototherapy.

Normal ranges for bilirubin levels vary depending on the age of the infant, the type of jaundice, and the method of measurement.Generally, bilirubin levels above 25 mg/dL are considered dangerous and require urgent treatment.

A. Mother’s ability to tolerate the discomfort of labor. B. Fetal lie. C. Well-being of the fetus. D. Maternal readiness for labor.

Correct Answer is C

Explanation

A nonstress test (NST) is a test in pregnancy that measures fetal heart rate and reaction to movement.Your pregnancy care provider performs a nonstress test to make sure the fetus is healthy and getting enough oxygen.It’s safe and painless, and gets its name because it puts no stress (nonstress) on you or the fetus.

Choice A is wrong because a nonstress test does not measure the mother’s ability to tolerate the discomfort of labor.A stress test is a different procedure that involves stimulating contractions and monitoring how the fetus responds.

Choice B is wrong because a nonstress test does not measure fetal lie, which is the position of the fetus in the uterus.

Fetal lie is usually determined by ultrasound or physical examination.

Choice D is wrong because a nonstress test does not measure maternal readiness for labor.A nonstress test typically happens after 28 weeks of pregnancy, when fetal heart rate starts reacting to movements.

Maternal readiness for labor is assessed by other factors, such as cervical dilation and effacement.

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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?

Nursing Test Bank

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Correct Answer is D

Explanation

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Correct Answer is C

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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?