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?

The correct answer is choice B. She works as a part-time oncology nurse.This is because oncology nurses are exposed toteratogenic agents, which are substances that can cause abnormalities in an exposed fetus.Teratogenic agents can cross the placenta and alter fetal morphology or function.Examples of teratogenic agents are lead, methyl mercury, polychlorinated biphenyls, lithium, vitamin K antagonists, tobacco, rubella, cytomegalovirus, ionizing agents, hyperthermia, diabetes, and some drugs.

Choice A is wrong because living with two dogs at home does not pose a high risk for exposure to teratogenic agents.Dogs can be beneficial for pregnant women as they provide companionship and exercise.

Choice C is wrong because being a lacto-ova vegetarian does not pose a high risk for exposure to teratogenic agents.Lacto-ova vegetarians can get adequate nutrition from plant-based foods, dairy products, and eggs.

Choice D is wrong because commuting to work on a train does not pose a high risk for exposure to teratogenic agents.Trains are a safe and convenient mode of transportation for pregnant women.

The correct answer is choice A. Maintaining the infants’ airways is the nurse’s priority when caring for a set of twins delivered by cesarean delivery.This is because twins are more likely to be born early and need special care after birth than single babies.They may have breathing difficulties or low oxygen levels and require oxygen therapy or ventilation.

The nurse should assess the infants’ respiratory status and intervene as needed.

Choice B is wrong because keeping the infants in a warm, draft-free environment is important but not as urgent as ensuring their airways are clear and they are breathing well.Premature twins may have trouble regulating their body temperature and need to be kept warm, but this can be done after their airways are secured.

Choice C is wrong because placing identification bands on the infants is a standard procedure but not a priority.

The nurse should make sure the infants are correctly identified and matched with their mother, but this can be done after their vital signs are stable.

Choice D is wrong because monitoring the infants’ vital signs is also important but not as urgent as maintaining their airways.

The nurse should check the infants’ heart rate, blood pressure, temperature and blood sugar levels regularly, but this can be done after their respiratory status is assessed and managed.

Normal ranges for vital signs in newborns are:

• Heart rate: 100 to 160 beats per minute

• Blood pressure: 50 to 75 mm Hg systolic and 30 to 45 mm Hg diastolic

• Temperature: 36.5 to 37.5°C (97.7 to 99.5°F)

• Blood sugar: 40 to 80 mg/dL