You, the RN, assess a client who is in the 32nd week of pregnancy.
She fell and punctured her leg with a nail.
She states she has not had a tetanus immunization since infancy.
Which action will you include in her plan of care?

Choice A rationale

Possible signs of pregnancy include symptoms like nausea, but feeling the baby move is not one of them.

Choice B rationale

Feeling fetal movements felt by both the mother and examiner is a positive sign of pregnancy as it confirms fetal presence.

Choice C rationale

Presumptive signs of pregnancy are symptoms felt by the woman, such as missed periods, but not confirmed fetal movements.

Choice D rationale

Probable signs include changes observed by an examiner, like a positive pregnancy test, but not confirmed fetal movements.

Choice A rationale

Increasing folic acid intake immediately is recommended because it helps prevent neural tube defects, which can occur very early in pregnancy, often before a woman knows she is pregnant.

Choice B rationale

Starting folic acid intake one week before her period is not sufficient. Folic acid needs to be taken consistently before conception and during early pregnancy to be effective.

Choice C rationale

Waiting until pregnancy is confirmed may be too late to prevent neural tube defects, which form in the early weeks of pregnancy.

Choice D rationale

If she misses her period, it might already be too late to prevent neural tube defects. Consistent intake of folic acid before and during early pregnancy is essential.