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 A

Explanation

The correct answer is choice A.Making a loud sound within close range of the newborn will elicit the Moro reflex, which is an involuntary protective motor response against abrupt disruption of body balance or extremely sudden stimulation.The Moro reflex involves three distinct components: spreading out the arms (abduction), pulling the arms in (adduction), and crying (usually).

Choice B is wrong because firmly stroking the soles of the newborn’s feet with a thumb nail will elicit the Babinski reflex, which is a normal response in infants that involves fanning out and curling of the toes.

Choice C is wrong because using the newborn’s hands to raise the baby from a supine position without supporting the head will elicit the traction response, which is a normal response in infants that involves flexion of the elbows and shoulders.

Choice D is wrong because holding the newborn in an upright position so that the infant’s feet touch a cool, flat surface will elicit the stepping reflex, which is a normal response in infants that involves alternating steps with each foot.

A. Sustained uterine hypertonicity. B. Strong uterine contractions every 3-4 minutes. C. Bile-colored vomitus. D. Fetal heart rate acceleration with fetal activity.

Correct Answer is A

Explanation

This means that the uterus is constantly contracted and does not relax between contractions.This can cause the placenta to separate from the uterine wall, which is called placental abruption or abruptio placentae.Placental abruption can deprive the baby of oxygen and nutrients and cause heavy bleeding in the mother.

Choice B is wrong because strong uterine contractions every 3-4 minutes are normal during labor and do not indicate placental abruption.

Choice C is wrong because bile-colored vomitus is not a sign of placental abruption, but rather a sign of hyperemesis gravidarum, a severe form of nausea and vomiting during pregnancy.

Choice D is wrong because fetal heart rate acceleration with fetal activity is a normal finding and indicates a healthy baby.Placental abruption can cause fetal distress and a decrease in fetal heart rate.

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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

When assessing a newborn, which is the best method for the nurse to use to elicit the Moro reflex?

Correct Answer is A

Explanation

A patient with no prenatal care is admitted to the labor and delivery unit.She is placed on an external fetal monitor, and an intravenous infusion is begun. A tentative diagnosis of abruptio placentae is made.Which finding would support this diagnosis?

Correct Answer is A

Explanation

On her second postpartum day, the mother of a newborn says, “The doctor says the baby has physiologic jaundice. Even though it is supposed to be normal, I don’t understand why it occurs.” Which fact regarding physiologic jaundice should form the basis of the nurse’s response?

A mother of a 3-hour-old infant requests information concerning breastfeeding. The mother has tested positive for human immunodeficiency virus (HIV).A nurse’s response should be based on which fact?

Which measure should be the nurse’s priority when caring for a set of twins delivered by cesarean delivery?

A nurse is caring for a client with gestational diabetes.Which guideline should the nurse use when providing nutritional counseling to this client?

A patient who is 26 weeks pregnant has gestational diabetes and is to begin insulin management. When discussing the patient’s insulin needs, which information should the nurse include?

The nurse instructs a postpartum patient in the use of a sitz bath. Which action by the patient indicates that the teaching was effective?

A nurse is caring for a patient who is receiving oxytocin injection intravenously for labor induction.The nurse should monitor this patient for which adverse effect of oxytocin?

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?