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. Count the time from the end of one contraction to the beginning of the next contraction. B. Count the time from the middle of one contraction to the end of the same contraction. C. Count the time from the beginning of one contraction to the end of the same contraction. D. Count the time from the beginning of one contraction to the beginning of the next contraction.

Correct Answer is C

Explanation

The correct answer is choice C. Count the time from the beginning of one contraction to the end of the same contraction.

This is because the duration of a contraction is the length of time that the uterine muscle is tightening and relaxing.

The duration is measured from the start of one contraction until the end of that same contraction.

Choice A is wrong because it measures the frequency of contractions, not the duration.

The frequency is the time between the start of one contraction and the start of the next one.

Choice B is wrong because it measures only half of the duration of a contraction.

The middle of a contraction is when the uterine muscle reaches its peak intensity and then starts to relax.

Choice D is wrong because it measures both the duration and the interval of contractions.

The interval is the time between the end of one contraction and the start of the next one.

Normal ranges for contractions during labor are:

• Duration: 30 to 90 seconds

• Frequency: 2 to 5 minutes apart

• Interval: 30 to 120 seconds

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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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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

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?