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.”.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. Position the patient in a left lateral position.This is because late fetal decelerations indicate uteroplacental insufficiency, which means that the placenta is not delivering enough oxygen to the fetus.By positioning the patient on her left side, the blood flow to the placenta and the fetus is improved.
Choice A is wrong because notifying the health care provider is not the first action that the nurse should take.The nurse should first intervene to correct the cause of fetal distress and then inform the provider.
Choice C is wrong because increasing the patient’s intravenous rate may not help with uteroplacental insufficiency.It may also cause fluid overload or pulmonary edema in the patient.
Choice D is wrong because providing the patient with oxygen via a face mask is not the most effective way to increase fetal oxygenation.Oxygen therapy may be used as an adjunct to other interventions, but it is not sufficient by itself.
Correct Answer is C
Explanation
The correct answer is choice C. Arrange for her to meet the staff who will be caring for her during labor and delivery.This measure can help reduce the anxiety and fear of the unknown that a primigravida may have in the last month of pregnancy.Meeting the staff can also help establish rapport and trust, which are essential for a positive birth experience.
Choice A is wrong because an increase in fetal activity does not necessarily require an increase in the need to rest.
Fetal activity is normal and expected, and the mother should monitor it regularly.Resting may help with some discomforts of pregnancy, but it is not directly related to fetal activity.
Choice B is wrong because back labor is not likely for a primigravida with an uncomplicated pregnancy.
Back labor occurs when the fetus is in an occiput posterior position, which puts pressure on the mother’s spine and causes intense pain in the lower back.This position is more common in multiparous women than primigravidas.
Choice D is wrong because testing urine for glucose is not a routine measure for a primigravida with an uncomplicated pregnancy.
Urine glucose testing is done for women who have gestational diabetes or are at risk of developing it.It is not necessary for women who have normal blood glucose levels.
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