A nurse is contributing to the plan of care for a client who is in the third trimester and reports difficulty sleeping. Which of the following statements should the nurse include?
"Drinking warm tea before bed can be helpful.”
"Doing relaxation exercises before bed can be helpful.”
"Sleeping on your right side can be helpful.”
"Soaking in a hot tub for 60 minutes can be helpful.”
The Correct Answer is B
Choice A reason:
The nurse should not recommend drinking warm tea before bed for a pregnant client. Certain herbal teas might not be safe during pregnancy, and caffeine-containing teas should be limited due to their potential effects on the fetus. Therefore, it is best to avoid suggesting this option to the client.
Choice B reason:
This is the correct choice as relaxation exercises can be beneficial for pregnant clients who are experiencing difficulty sleeping. These exercises can help reduce stress, promote relaxation, and improve sleep quality without any adverse effects on the client or the baby.
Choice C reason:
The nurse should avoid recommending that the client sleep on their right side. While the left side is generally recommended during pregnancy to improve blood flow to the placenta and baby, sleeping on the right side is not harmful either. However, it is better to provide the most suitable option for promoting sleep, which is relaxation exercises as mentioned in Choice B.
Choice D reason:
Soaking in a hot tub for 60 minutes is not advisable during pregnancy. Prolonged exposure to high temperatures, such as in hot tubs or saunas, can raise the body's core temperature, potentially causing harm to the developing fetus. Pregnant individuals should avoid hot tubs to prevent overheating.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice C reason: The infant makes babbling sounds. At 6 months of age, it is typical for infants to engage in babbling sounds. Babbling is a significant milestone in language development during infancy. It involves the repetition of consonant-vowel combinations (e.g., "ba-ba,”. "ma-ma") and is an essential precursor to later language skills, such as forming words and sentences. The nurse should expect the 6-month-old infant to be making these babbling sounds as part of their normal development.
Choice A reason:
The infant has a pincer grasp. A pincer grasp is the ability to pick up small objects using the thumb and index finger. This fine motor skill typically develops around 9 to 12 months of age. At 6 months old, infants have not yet acquired the pincer grasp. Therefore, the nurse should not expect the 6-month-old infant to demonstrate this skill during the assessment.
Choice D reason:
The infant crawls on their hands and knees. Crawling is a gross motor skill that usually emerges between 7 to 10 months of age. While some infants may start crawling earlier or later, it is not a skill that is typically present in a 6-month-old. Therefore, the nurse should not anticipate the 6-month-old infant to be crawling on their hands and knees during the assessment.
Choice B reason:
The infant drops objects with the expectation of someone picking them up. This behavior, known as "object permanence,”. is a cognitive milestone that develops around 8 to 12 months of age. At 6 months old, infants have not yet fully developed this concept. They might drop objects as part of their exploratory behavior, but they do not yet understand the expectation of someone picking them up. Therefore, the nurse should not expect the 6- month-old infant to exhibit this specific behavior during the assessment.
Correct Answer is B
Explanation
Choice A reason:
Obtaining vital signs is essential in assessing the child's overall condition, but it is not the first action the nurse should take in this situation. The priority is to address the immediate concern of difficulty breathing.
Choice B reason:
Stopping the IV infusion is the most critical action the nurse should take first. Difficulty breathing can be a sign of a severe allergic reaction, and if it is related to the IV cefuroxime, stopping the infusion will prevent further administration of the medication and possibly worsening the reaction.
Choice C reason:
Administering epinephrine IM is not the first-line action in this scenario. Epinephrine is used in severe anaphylactic reactions, but it should not be given without a proper evaluation of the situation and a clear indication for its use.
Choice D reason:
Monitoring intake and output is an important nursing intervention, but it is not the priority when the child is experiencing difficulty breathing. Addressing the respiratory distress should be the initial focus to ensure the child's safety and well-being.
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