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 increase in maternal blood volume is greater than the increase in maternal red blood cells.

This means that the concentration of hemoglobin and hematocrit in the blood is diluted by the extra fluid.

This is a normal physiological adaptation to pregnancy and does not indicate iron deficiency anemia.

Choice A is wrong because placental hormones do not chelate maternal iron.

Chelation is a process of binding metal ions to organic molecules, which is not relevant to this question.

Choice B is wrong because fetal demand for iron is not greater than maternal intake.

The mother can meet the iron needs of the fetus by increasing her dietary intake and taking iron supplements.

Choice C is wrong because maternal intestinal absorption of iron is not decreased during pregnancy.

In fact, it may be increased due to higher levels of estrogen and progesterone.

A. Have her do Kegel exercises once an hour. B. Apply ice to her perineal area. C. Keep her hips slightly elevated. D. Observe her perineal area for signs of infection.

Correct Answer is B

Explanation

The correct answer is choice B. Apply ice to her perineal area.This is because ice can help reduce swelling and pain in the episiotomy wound, which is a cut made in the tissue between the vagina and anus during childbirth.Ice should be applied for the first 24 to 48 hours after delivery.

Choice A is wrong because Kegel exercises, which involve contracting and relaxing the pelvic floor muscles, are not recommended for the first 12 hours after an episiotomy.They can increase blood flow and inflammation in the area, and may interfere with healing.

Choice C is wrong because keeping her hips slightly elevated can cause pressure on the episiotomy wound and increase discomfort.It can also affect blood circulation and drainage in the area.

Choice D is wrong because observing her perineal area for signs of infection is not a nursing action that should be included in her plan of care for the first 12 hours.Infection is rare in episiotomy wounds, and signs of infection usually appear after 24 hours or later.However, the nurse should teach the patient how to keep the area clean and dry, and when to report any signs of infection, such as fever, pus, or foul-smelling discharge.

Normal ranges for episiotomy healing are:

• Stitches dissolve within 2 to 4 weeks

• Pain and swelling subside within a few days to a week

• Wound heals completely within 4 to 6 weeks

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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?

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Correct Answer is D

Explanation

A patient had an episiotomy during her delivery. Which nursing action should be included in her plan of care for the first 12 hours?

Correct Answer is B

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?