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 D

Explanation

The correct answer is choice D: To prevent her from having convulsions.Magnesium sulfate is a mineral that reduces seizure risks in women with preeclampsia, a condition of high blood pressure and protein in the urine during pregnancy.Magnesium sulfate can lower the cerebral perfusion pressure and prevent convulsions.However, magnesium sulfate does not affect the neonatal outcomes and can cause side effects such as respiratory depression.

Choice A is wrong because magnesium sulfate does not decrease blood pressure.It is used along with medications that help reduce blood pressure.

Choice B is wrong because magnesium sulfate does not decrease tidal volume.It can cause respiratory depression if the serum level is too high.

Choice C is wrong because magnesium sulfate does not prevent dehydration.It can cause fluid retention and pulmonary edema if given in excess.

A. The fetal heart rate decreases after the start of a contraction and returns to the baseline 60 seconds after the end of the contraction. B. There is a six to ten beat-to-beat variability in the fetal heart rate. C. The fetal heart rate accelerates five to seven beats just prior to the beginning of a contraction. D. The fetal heart rate decreases at the start of the contraction and returns to baseline by the end of the contraction.

Correct Answer is A

Explanation

The correct answer is choice A and it indicates fetal distress because it is a sign oflate deceleration.Late decelerations are due touteroplacental insufficiencyas the result of decreased blood flow and oxygen to the fetus during the uterine contractions.This causeshypoxemiaand can lead to fetal acidosis and neurological damage.

Choice B is wrong because it indicates anormal variabilityin the fetal heart rate, which reflects a healthy autonomic nervous system.A normal fetal heart rate is 120-160 beats per minute.

Choice C is wrong because it indicates anearly accelerationin the fetal heart rate, which is a benign finding that may occur with fetal movement or stimulation.

Choice D is wrong because it indicates anearly decelerationin the fetal heart rate, which is a normal response to fetal head compression during contractions.

It does not indicate fetal distress.

Normal ranges for fetal heart rate patterns are:

• Baseline: 120-160 beats per minute

• Variability: 6-25 beats per minute

• Accelerations: at least 15 beats per minute above baseline for at least 15 seconds

• Decelerations: none or early (mirror contractions)

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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

A patient diagnosed with preeclampsia is admitted to the hospital and prescribed magnesium sulfate therapy. What is the purpose of administering magnesium sulfate to this patient?

Correct Answer is D

Explanation

A nurse caring for a patient in labor is evaluating the fetal heart monitor.Which finding would indicate fetal distress?

Correct Answer is A

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?