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

The correct answer is choice D. The fluid that the mother has in her breasts before the milk comes in is called colostrum, which is rich in antibodies and nutrients that the baby needs.

It also helps to prevent jaundice by stimulating the baby’s bowel movements.

Therefore, the nurse should encourage the mother to breastfeed as soon as possible after birth and explain the benefits of colostrum.

Choice A is wrong because it discourages breastfeeding and may interfere with milk production and bonding.

Choice B is wrong because it implies that breastfeeding is only a skill and not a natural process that benefits both the mother and the baby.

Choice C is wrong because it focuses on the emotional aspect of breastfeeding and not the physiological one.

While breastfeeding may enhance the closeness between the mother and the baby, it is not the only reason to breastfeed.

A. Sustained uterine hypertonicity. B. Strong uterine contractions every 3-4 minutes. C. Bile-colored vomitus. D. Fetal heart rate acceleration with fetal activity.

Correct Answer is A

Explanation

This means that the uterus is constantly contracted and does not relax between contractions.This can cause the placenta to separate from the uterine wall, which is called placental abruption or abruptio placentae.Placental abruption can deprive the baby of oxygen and nutrients and cause heavy bleeding in the mother.

Choice B is wrong because strong uterine contractions every 3-4 minutes are normal during labor and do not indicate placental abruption.

Choice C is wrong because bile-colored vomitus is not a sign of placental abruption, but rather a sign of hyperemesis gravidarum, a severe form of nausea and vomiting during pregnancy.

Choice D is wrong because fetal heart rate acceleration with fetal activity is a normal finding and indicates a healthy baby.Placental abruption can cause fetal distress and a decrease in fetal heart rate.

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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

Naxlex Comprehensive Predictor Exams

During the first postpartum day, a new mother is breastfeeding her infant.The client asks, “Since I don’t have any milk yet, why am I breastfeeding?” Which response by the nurse is most appropriate?

Correct Answer is D

Explanation

A patient with no prenatal care is admitted to the labor and delivery unit.She is placed on an external fetal monitor, and an intravenous infusion is begun. A tentative diagnosis of abruptio placentae is made.Which finding would support this diagnosis?

Correct Answer is A

Explanation

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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?