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.
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Related Questions
Correct Answer is B
Explanation
This is because late fetal heart rate decelerations are a sign of uteroplacental insufficiency, which means that the placenta is not delivering enough oxygen and nutrients to the fetus.Oxytocin can cause uterine tachysystole, which is excessive and frequent contractions that reduce blood flow to the placenta.Therefore, stopping the oxytocin infusion can help improve placental perfusion and fetal oxygenation.
Choice A is wrong because documenting the findings is not a priority action in this situation.
The nurse should first intervene to address the cause of late decelerations and then document the actions and outcomes.
Choice C is wrong because raising the head of the patient’s bed 30 degrees does not directly affect the placental blood flow or fetal oxygenation.
It may help with maternal comfort and breathing, but it is not an essential action for late decelerations.
Choice D is wrong because notifying the health care provider is not the first action to take.The nurse should first attempt to correct the cause of late decelerations by pausing the oxytocin infusion and then notify the health care provider if there is no improvement or if there are other signs of fetal distress.
Correct Answer is B
Explanation
The correct answer is choice B. Taking mineral oil each night is not recommended for pregnant women who have hemorrhoids because it can interfere with the absorption of fat-soluble vitamins and cause diarrhea, which can worsen hemorrhoids.
The patient should avoid laxatives and stool softeners unless prescribed by a health care provider.
Choice A is wrong because walking at least a mile a day can help improve blood circulation and prevent constipation, which are both beneficial for hemorrhoid management.
Choice C is wrong because including foods high in fiber in the diet can help soften stools and prevent straining, which can aggravate hemorrhoids.
Choice D is wrong because drinking one extra glass of water before breakfast each morning can help hydrate the body and prevent dehydration, which can cause hard stools and increase pressure on the anal veins.
The nurse should teach the patient other strategies for hemorrhoid management, such as applying ice packs or witch hazel pads to the affected area, using sitz baths or warm water baths, avoiding prolonged sitting or standing, and wearing cotton underwear.
The nurse should also advise the patient to report any signs of infection or bleeding to the health care provider.
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