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 D
Explanation
The correct answer is choice D. Apply petrolatum to the patient’s perineum.This is because petrolatum can help soothe and protect the perineal area, which may be swollen, bruised, or have stitches after a vaginal delivery.Applying petrolatum can also prevent the pad from sticking to the wound and causing more pain.
Choice A is wrong because observing the patient for vaginal discharge of bright red blood is not a specific action for perineal care.Bright red blood may indicate postpartum hemorrhage, which requires immediate medical attention.
Choice B is wrong because assessing the patient’s vaginal tone is not a priority action for perineal care.Vaginal tone may be reduced after childbirth due to stretching of the pelvic floor muscles, but this can improve with time and exercises.
Choice C is wrong because massaging the patient’s perineum is not recommended for perineal care.Massaging the perineum may cause more trauma and discomfort to the area, especially if there are stitches or hemorrhoids.Massaging the fundus (the top of the uterus) may be done to help it contract and prevent bleeding, but this is different from massaging the perineum.
Correct Answer is C
Explanation
This is because urine toxicology studies can detect the presence of cocaine and other drugs in the body of the pregnant woman and her unborn baby.Cocaine use during pregnancy can have serious consequences for both the mother and the baby, such as high blood pressure, premature labor, low birth weight, and developmental problems.
Choice A is wrong because urine estriol levels are used to measure the activity of the placenta and the fetal adrenal glands.They are not related to cocaine use.
Choice B is wrong because serum bilirubin levels are used to assess the liver function and the risk of jaundice in newborns.They are not related to cocaine use.
Choice D is wrong because lecithin-sphingomyelin ratio is used to evaluate the fetal lung maturity and the risk of respiratory distress syndrome.It is not related to cocaine use.
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