Author Question: A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells ... (Read 59 times)

kaid0807 · **on:** Jul 22, 2018

A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions. The nurse determines that the client is expe-riencing Braxton Hicks contractions.

Which of the following nursing actions would be appropri-ate? 1. Contact the physician.
2. Instruct the client to maintain bed rest for the remainder of the pregnancy.
3. Instruct the client that these are common and may occur throughout the pregnan-cy.
4. Call the maternity unit and inform them that the client will be admitted in a pre-labor condition.

Question 2

In which of the following optimal positions should the nurse plan to place the client after bolus feeding using a nasogastric tube?

1. Head of bed (HOB) flat, with client supine for at least 60 minutes
2. HOB elevated 45 to 60 degrees, with client supine for 15 minutes
3. HOB elevated 10 degrees, with client in the left lateral position for 60 minutes
4. HOB elevated 30 to 45 degrees, with client in the right lateral position for 60 minutes

scrocafella · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

3

Rationale: Braxton Hicks contractions are irregular painless contractions that occur throughout pregnancy, although many expectant mothers do not notice them until the third trimester. Be-cause Braxton Hicks contractions may occur and are normal in some pregnant women during pregnancy, the other options are unnecessary and inaccurate.

Answer to Question 2

4

Rationale: Aspiration is a possible complication associated with nasogastric tube feeding. The HOB should be elevated 30 to 45 degrees for 30 to 60 minutes following bolus tube feeding to prevent vomiting and aspiration. The right lateral position uses gravity to facilitate gastric emptying, which also will reduce the risk of vomiting. The flat supine position should be avoided for the first 30 minutes after a tube feeding.