A client who is 22 weeks pregnant with a twin gestation comes to the clinic.
The nurse instructs the client in self-care for the third trimester of pregnancy. Which statement made by the client would indicate the need for further teaching?

“I have begun to smooth cocoa butter on my belly.”.

“I am resting several times a day, lying on my left side.”.

“I have started to do nipple stimulation.”.

“I will drink at least eight glasses of water a day.”.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C and explain why. Nipple stimulation can cause uterine contractions and increase the risk of preterm labor, especially in a twin gestation.

The client should avoid nipple stimulation until term or as instructed by the provider.

Choice A is wrong because cocoa butter can help moisturize the skin and prevent itching and dryness.

It does not prevent stretch marks, but it is not harmful.

Choice B is wrong because resting several times a day, lying on the left side, can improve blood flow to the uterus and reduce swelling in the lower extremities.

It is a recommended self-care measure for the third trimester of pregnancy.

Choice D is wrong because drinking at least eight glasses of water a day can prevent dehydration, constipation, and urinary tract infections.

It can also help regulate body temperature and amniotic fluid volume.

Normal ranges for twin gestation are similar to singleton gestation, except for fundal height and weight gain.

The fundal height should be measured in centimeters from the pubic symphysis to the top of the uterus.

It should be approximately equal to the number of weeks of gestation plus or minus 4 cm until 32 weeks, then it may plateau or decrease slightly.

The weight gain should be between 35 and 45 pounds for a normal-weight woman, 25 to 42 pounds for an overweight woman, and 15 to 25 pounds for an obese woman.

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Correct Answer is B

Explanation

The correct answer is choice B. Dry off the newborn.This is the priority nursing action because it prevents heat loss and hypothermia in the newborn.

The newborn has a large surface area and a thin layer of subcutaneous fat, making it vulnerable to cold stress.Drying off the newborn also stimulates breathing and crying, which helps clear the airways.

Choice A is wrong because obtaining a serum sample is not a priority action and may cause unnecessary pain and bleeding in the newborn.

Choice C is wrong because assessing the newborn’s Moro reflex is not a priority action and may be done later during the physical examination.Choice D is wrong because obtaining the newborn’s footprints is not a priority action and may be done after the bonding and breastfeeding period.

A. Count the time from the end of one contraction to the beginning of the next contraction. B. Count the time from the middle of one contraction to the end of the same contraction. C. Count the time from the beginning of one contraction to the end of the same contraction. D. Count the time from the beginning of one contraction to the beginning of the next contraction.

Correct Answer is C

Explanation

The correct answer is choice C. Count the time from the beginning of one contraction to the end of the same contraction.

This is because the duration of a contraction is the length of time that the uterine muscle is tightening and relaxing.

The duration is measured from the start of one contraction until the end of that same contraction.

Choice A is wrong because it measures the frequency of contractions, not the duration.

The frequency is the time between the start of one contraction and the start of the next one.

Choice B is wrong because it measures only half of the duration of a contraction.

The middle of a contraction is when the uterine muscle reaches its peak intensity and then starts to relax.

Choice D is wrong because it measures both the duration and the interval of contractions.

The interval is the time between the end of one contraction and the start of the next one.

Normal ranges for contractions during labor are:

• Duration: 30 to 90 seconds

• Frequency: 2 to 5 minutes apart

• Interval: 30 to 120 seconds

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A client who is 22 weeks pregnant with a twin gestation comes to the clinic. The nurse instructs the client in self-care for the third trimester of pregnancy. Which statement made by the client would indicate the need for further teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Just after a client delivers a baby who weighs 7 pounds (3.18 kg), what is the priority nursing action?

Correct Answer is B

Explanation

A nurse is caring for a patient who is in labor and is placed on a monitor.How should the nurse determine the duration of contractions?

Correct Answer is C

Explanation

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A client who is 22 weeks pregnant with a twin gestation comes to the clinic.
The nurse instructs the client in self-care for the third trimester of pregnancy. Which statement made by the client would indicate the need for further teaching?