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 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.
Correct Answer is D
Explanation
The correct answer is choice D. Gestational age of 35-38 weeks.
This is because preterm babies are more likely to develop jaundice due to their immature liver and increased breakdown of red blood cells.Babies born between 35 and 38 weeks are considered late preterm and have a higher risk of jaundice than full-term babies.
Choice A is wrong because African American ethnicity is not a risk factor for jaundice.In fact, Asian, European, or native American ethnicity are more associated with jaundice.
Choice B is wrong because meconium-stained amniotic fluid is not a risk factor for jaundice.
Meconium is the first stool of the baby and it may indicate fetal distress, but it does not affect the bilirubin level.
Choice C is wrong because bottle feeding is not a risk factor for jaundice.In fact, breastfeeding is more associated with jaundice due to dehydration and poor caloric intake.
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