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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This is because urine toxicology studies can detect the presence of cocaine and other drugs in the body of the pregnant woman and her unborn baby.Cocaine use during pregnancy can have serious consequences for both the mother and the baby, such as high blood pressure, premature labor, low birth weight, and developmental problems.
Choice A is wrong because urine estriol levels are used to measure the activity of the placenta and the fetal adrenal glands.They are not related to cocaine use.
Choice B is wrong because serum bilirubin levels are used to assess the liver function and the risk of jaundice in newborns.They are not related to cocaine use.
Choice D is wrong because lecithin-sphingomyelin ratio is used to evaluate the fetal lung maturity and the risk of respiratory distress syndrome.It is not related to cocaine use.
Correct Answer is A
Explanation
The correct answer is choice A and it indicates fetal distress because it is a sign oflate deceleration.Late decelerations are due touteroplacental insufficiencyas the result of decreased blood flow and oxygen to the fetus during the uterine contractions.This causeshypoxemiaand can lead to fetal acidosis and neurological damage.
Choice B is wrong because it indicates anormal variabilityin the fetal heart rate, which reflects a healthy autonomic nervous system.A normal fetal heart rate is 120-160 beats per minute.
Choice C is wrong because it indicates anearly accelerationin the fetal heart rate, which is a benign finding that may occur with fetal movement or stimulation.
Choice D is wrong because it indicates anearly decelerationin the fetal heart rate, which is a normal response to fetal head compression during contractions.
It does not indicate fetal distress.
Normal ranges for fetal heart rate patterns are:
• Baseline: 120-160 beats per minute
• Variability: 6-25 beats per minute
• Accelerations: at least 15 beats per minute above baseline for at least 15 seconds
• Decelerations: none or early (mirror contractions)
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