# Situation: A 30-year-old primigravida at 30 weeks' gestation attends a prenatal check-up at a lying-in clinic. Her pregnancy has been uncomplicated so far. She complains of heartburn after meals and low back pain at the end of the day. She takes the iron–folic acid tablet from the health center each morning. The nurse teaches her how to relieve the burning in her chest after meals. Which statement by the client shows that she needs **FURTHER** teaching?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629372  
> language: ko  
> subject: Nursing Practice II — Maternal and Child Health Nursing

## 문제

Situation: A 30-year-old primigravida at 30 weeks' gestation attends a prenatal check-up at a lying-in clinic. Her pregnancy has been uncomplicated so far. She complains of heartburn after meals and low back pain at the end of the day. She takes the iron–folic acid tablet from the health center each morning.

The nurse teaches her how to relieve the burning in her chest after meals. Which statement by the client shows that she needs **FURTHER** teaching?

## 보기

1. "I will eat small meals and stay upright for 1 to 2 hours after eating."
2. "I will ask the clinic which antacid is safe for me to use."
3. "I will raise the head of my bed when I go to sleep."
4. "I will take my antacid with my morning iron tablet." **✔ 정답**

**정답: 4**

## 해설

Heartburn in pregnancy comes from progesterone relaxing the lower esophageal sphincter and the uterus pushing the stomach up. Small meals, staying upright after eating, raising the head of the bed, and using only clinician-approved antacids are correct. Antacids reduce iron absorption, so the antacid and the iron tablet must be taken at different times.

## 심화 해설

Why option 4 is the statement that needs further teaching

Heartburn during pregnancy is driven by two main mechanisms. First, progesterone relaxes the lower esophageal sphincter, reducing the pressure that normally keeps gastric contents from refluxing upward [2]. Second, the enlarging uterus displaces the stomach upward and increases intra-abdominal pressure, which further promotes reflux of acidic contents into the esophagus [1][2]. The client’s statements about small meals, staying upright after eating, raising the head of the bed, and asking about a safe antacid all reflect appropriate self-management strategies that align with the step-up approach beginning with lifestyle modification [1][2].

The critical error in option 4 is the timing of the antacid relative to the iron tablet. Antacids work by neutralizing gastric acid, but this same action interferes with iron absorption. Iron is best absorbed in an acidic environment, and antacids raise gastric pH, reducing the conversion of iron to its absorbable form. Key point! The antacid and iron tablet must be separated by at least 1 to 2 hours, and they should not be taken together at the same time.

Why the other options are correct

Option 1 reflects sound advice. Eating smaller, more frequent meals reduces gastric distention and therefore reduces the volume of refluxate available to enter the esophagus. Remaining upright for 1 to 2 hours after meals uses gravity to keep gastric contents below the gastroesophageal junction while the stomach empties [1][2].

Option 2 is appropriate because not all antacids are equally safe during pregnancy. Some formulations contain sodium bicarbonate or magnesium trisilicate, which may be less desirable due to fluid retention or other effects. Asking the clinic which antacid is safe reflects appropriate caution and aligns with the principle that drug therapy during pregnancy should be clinician-guided [1][2].

Option 3 is also correct. Elevating the head of the bed reduces nocturnal reflux by using gravity to keep gastric contents in the stomach while the client is supine. This is a standard lifestyle modification recommended before or alongside drug therapy [1][2].

Clinical reasoning for the licensure exam

This question tests the ability to identify a drug–drug interaction in the context of pregnancy-related discomfort. The client has two separate issues: iron supplementation for pregnancy-related anemia prevention and heartburn from gestational reflux. The exam expects the nurse to recognize that antacids reduce iron absorption and that these two agents must be spaced apart.

| Intervention | Mechanism of benefit | Timing or precaution |
| --- | --- | --- |
| Small frequent meals | Reduces gastric distention and reflux volume | Throughout the day |
| Stay upright after meals | Gravity limits reflux into esophagus | 1–2 hours postprandial |
| Elevate head of bed | Reduces nocturnal reflux | During sleep |
| Antacid use | Neutralizes refluxed gastric acid | Separate from iron by 1–2 hours |

Watch out! The exam may phrase the correct answer as “take the antacid and iron together to simplify the regimen.” That is always wrong because the interaction is predictable and clinically significant. Iron absorption depends on an acidic gastric environment; antacids raise pH and impair that absorption.

The prevalence of reflux symptoms in pregnancy is high, with estimates reaching up to 80% in some reviews [1]. Because the condition is so common, nurses must be able to teach both lifestyle measures and safe medication timing. The step-up approach begins with lifestyle changes, and when drug therapy is needed, antacids or sucralfate are considered first-line options [1][2]. However, the interaction with iron supplementation is a distinct teaching point that applies specifically to pregnant clients taking both agents.

The client who says she will take her antacid with her morning iron tablet has not yet understood that these two medications must be separated in time to preserve iron absorption. This is the statement that indicates a need for further teaching.References (research sources)

- [1]Review article: the management of heartburn during pregnancy and lactation.Research articleThélin CS, Richter JE (2020) · DOI: 10.1111/apt.15611

- [2]Review article: the management of heartburn in pregnancy.Research articleRichter JE (2005) · DOI: 10.1111/j.1365-2036.2005.02654.x

## 임상 시나리오

Antacid and Iron Timing in PregnancyPreventing drug interaction while managing heartburn
Antacids neutralize gastric acid and raise gastric pH, which impairs iron absorption. Iron requires an acidic environment for optimal uptake in the duodenum.

Separate antacid and iron doses by at least 1 to 2 hours. Do not administer them together at the same time.

CautionOnly use clinician-approved antacids during pregnancy. Assess the client's full medication list for other pH-dependent drugs that may also interact with antacids.

## 핵심 개념

- **Lower esophageal sphincter (LES)** — The muscular ring at the gastroesophageal junction that normally prevents reflux; progesterone relaxes it during pregnancy.
- **Iron absorption** — The process by which dietary or supplemental iron is taken up in the duodenum; requires an acidic environment for optimal absorption.
- **Antacid** — A medication that neutralizes gastric acid; raises gastric pH and can impair absorption of iron and other pH-dependent drugs.
- **Gastric pH** — The acidity level of stomach contents; antacids increase pH, which reduces conversion of iron to its absorbable form.
- **Drug interaction** — A situation where one medication alters the effect or absorption of another; antacid-iron is a classic example requiring separated dosing.

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