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 C
Explanation
The correct answer is choice C. Have a suction catheter available for use at delivery.This is because meconium-stained amniotic fluid indicates that the fetus has passed meconium (first stool) before birth, which can be a sign of fetal distress or hypoxia.Meconium can block the airways and cause breathing problems for the newborn, so suctioning the mouth and nose (or the trachea if needed) is important to prevent meconium aspiration syndrome.
Choice A is wrong because taking the mother’s vital signs every 15 minutes is not a specific intervention for meconium-stained amniotic fluid.
Vital signs should be monitored regularly during labor regardless of the fluid color.
Choice B is wrong because sending a specimen of the fluid to the laboratory for analysis is not a priority action.The color and consistency of the fluid can be observed by the nurse and documented.
The laboratory analysis will not change the immediate management of the newborn.
Choice D is wrong because preparing a slide of the fluid for fern testing is not relevant for meconium-stained amniotic fluid.
Fern testing is used to confirm the rupture of membranes by detecting a fern-like pattern of amniotic fluid under a microscope.It is not useful for assessing the presence or severity of meconium-stained amniotic fluid.
Correct Answer is D
Explanation
The correct answer is choice D. The fluid that the mother has in her breasts before the milk comes in is called colostrum, which is rich in antibodies and nutrients that the baby needs.
It also helps to prevent jaundice by stimulating the baby’s bowel movements.
Therefore, the nurse should encourage the mother to breastfeed as soon as possible after birth and explain the benefits of colostrum.
Choice A is wrong because it discourages breastfeeding and may interfere with milk production and bonding.
Choice B is wrong because it implies that breastfeeding is only a skill and not a natural process that benefits both the mother and the baby.
Choice C is wrong because it focuses on the emotional aspect of breastfeeding and not the physiological one.
While breastfeeding may enhance the closeness between the mother and the baby, it is not the only reason to breastfeed.
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