At a prenatal visit at 36 weeks' gestation, a client complains of discomfort with irregularly occurring contractions (Braxton Hicks contractions). The nurse instructs the client to:
Walk around and increase fluid intake.
Time contractions for 30 minutes.
Take aspirin for the discomfort.
Go to the hospital.
The Correct Answer is A
Choice A rationale
Walking and increasing fluid intake can often alleviate the discomfort associated with Braxton Hicks contractions. Movement can sometimes cause the uterus to relax, and adequate hydration helps maintain uterine irritability within normal physiological limits. Dehydration can sometimes exacerbate uterine contractions, so ensuring sufficient fluid intake is a prudent measure.
Choice B rationale
Timing contractions is more relevant when assessing for true labor. Braxton Hicks contractions are irregular and do not follow a consistent pattern of increasing frequency, duration, and intensity. Instructing the client to time them for 30 minutes may cause unnecessary anxiety and is not the primary intervention for discomfort relief.
Choice C rationale
Aspirin is not recommended during pregnancy, especially in the third trimester, due to potential risks to both the mother and the fetus, such as increased bleeding tendencies. Furthermore, aspirin would not address the physiological cause of Braxton Hicks contractions.
Choice D rationale
Going to the hospital is not indicated for irregular, non-painful Braxton Hicks contractions, especially at 36 weeks' gestation. Hospital visits are reserved for signs of true labor, such as regular, increasing contractions, rupture of membranes, or significant bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Thoroughly cooking meat to an internal temperature of 160°F (71°C) kills the Toxoplasma gondii parasite, thus preventing transmission. This is a recommended measure to prevent toxoplasmosis during pregnancy.
Choice B rationale
Drinking unpasteurized milk poses a risk of exposure to various pathogens, including Toxoplasma gondii, as pasteurization is a process that kills harmful microorganisms. Pregnant women should avoid unpasteurized dairy products to reduce the risk of infection. This statement indicates a need for further instruction as it suggests an unsafe practice.
Choice C rationale
Cat feces can contain oocysts of Toxoplasma gondii. Avoiding contact with materials potentially contaminated with cat feces, such as litter boxes or garden soil, is a crucial measure to prevent toxoplasmosis.
Choice D rationale
Raw meat can be contaminated with Toxoplasma gondii. Avoiding touching mucous membranes of the mouth or eyes while handling raw meat and washing hands thoroughly afterwards prevents the parasite from entering the body. This is a recommended preventive measure.
Correct Answer is B
Explanation
Choice A rationale
A glucose reading of 58 mg/dL in a newborn is below the normal range (typically 40-60 mg/dL in the first hours of life, rising to 50-90 mg/dL). While this requires intervention to prevent hypoglycemia, other parameters might indicate a more immediate threat to the newborn's well-being.
Choice B rationale
A temperature of 97.4°F (36.3°C) is below the normal range for a newborn (typically 97.7°F to 99.5°F or 36.5°C to 37.5°C). Hypothermia in a newborn can lead to cold stress, increasing oxygen and glucose consumption, potentially leading to respiratory distress and hypoglycemia. Therefore, a low temperature requires immediate assessment and intervention to warm the newborn.
Choice C rationale
A respiratory rate of 48 breaths/minute is within the normal range for a newborn (typically 30-60 breaths/minute). While the respiratory rate should be monitored, it does not indicate an immediate critical issue in this case.
Choice D rationale
A pulse of 134 beats/minute is within the normal range for a newborn (typically 110-160 beats/minute). While the heart rate should be monitored, it does not indicate an immediate critical issue in this case. .
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