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. The patient should palpate her breasts using the padded sections of her fingers.This is the recommended technique for breast self-examination, as it allows the patient to feel any changes or lumps in the breast tissue.
Choice A is wrong because the patient should perform breast self-examination at the same time each month, preferably a few days after the menstrual period ends when the breasts are less likely to be swollen or tender.
Choice B is wrong because the patient should not assume that any lumps that are present in both breasts are normal.Some breast cancers can affect both breasts, and any new or unusual lumps should be reported to a doctor.
Choice D is wrong because the patient should look at her breasts while standing in front of the mirror with her arms at her sides, raised overhead, and pressed firmly on her hips.She should also look for any changes in the shape, size, color, or texture of her breasts and nipples.
Correct Answer is C
Explanation
This is because a normal fetal heart rate is between 110 and 160 beats per minute, and the range of 136 to 143 indicates that the fetus is well-oxygenated and not experiencing hypoxia or acidosis. The nurse should reassure the patient and explain that fetal movement may decrease during labor due to the pressure of the contractions on the uterus and the fetus.
Choice A is wrong because asking the patient about alcohol consumption is irrelevant and insensitive.
Alcohol can affect fetal development and growth, but it does not directly affect fetal movement or heart rate.
Choice B is wrong because bloody vaginal discharge, or bloody show, is a normal sign of cervical dilation and effacement during labor.
It does not indicate fetal distress or placental abruption.
Choice D is wrong because explaining the relationship between anxiety and fetal movement does not address the patient’s concern or provide any factual information.
Anxiety can affect maternal perception of fetal movement, but it does not cause fetal movement to decrease.
The nurse should validate the patient’s feelings and provide factual reassurance.
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