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 A

Explanation

The correct answer is choice B. Test the patient’s vaginal secretions with nitrazine paper.

Nitrazine Paper pH on Amniotic Fluid - ppt video online download

This is because the patient may be leaking amniotic fluid rather than urine, and nitrazine paper can help differentiate between the two by testing the pH level.Amniotic fluid is alkaline and will turn the paper blue, while urine is acidic and will turn the paper yellow.

Choice A is wrong because checking the patient’s bladder for distention will not help determine if the patient is leaking amniotic fluid or urine.

Choice C is wrong because checking the patient’s urine for glucose content will not help determine if the patient is leaking amniotic fluid or urine.

Glucose content may be elevated in patients with gestational diabetes, but this is not related to the patient’s complaint.

Choice D is wrong because obtaining a specimen of the patient’s vaginal secretions for culture will not help determine if the patient is leaking amniotic fluid or urine.

Culture may be done to check for infections, but this is not the initial action that the nurse should take.

A. Notify the health care provider. B. Position the patient in a left lateral position. C. Increase the patient’s intravenous rate. D. Provide the patient with oxygen via a face mask.

Correct Answer is B

Explanation

The correct answer is choice B. Position the patient in a left lateral position.This is because late fetal decelerations indicate uteroplacental insufficiency, which means that the placenta is not delivering enough oxygen to the fetus.By positioning the patient on her left side, the blood flow to the placenta and the fetus is improved.

Choice A is wrong because notifying the health care provider is not the first action that the nurse should take.The nurse should first intervene to correct the cause of fetal distress and then inform the provider.

Choice C is wrong because increasing the patient’s intravenous rate may not help with uteroplacental insufficiency.It may also cause fluid overload or pulmonary edema in the patient.

Choice D is wrong because providing the patient with oxygen via a face mask is not the most effective way to increase fetal oxygenation.Oxygen therapy may be used as an adjunct to other interventions, but it is not sufficient by itself.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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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?