The home health nurse is visiting the home of a client who is 18 ...

[tatyanajohnson]

The home health nurse is visiting the home of a client who is 18 weeks pregnant with twins. Which nursing action is most important?
 
  1. Assess the client's blood pressure in the upper right arm.
  2. Collect a cervicovaginal fetal fibronectin (fFN) specimen.
  3. Teach the client about foods that are good sources of protein.
  4. Determine whether the pregnancy is a result of infertility treatment.

Question 2

A pregnant client is diagnosed with central abruptio placentae. What can the nurse infer about the client's condition?
 
  1. The slight separation of the client's placenta from the uterine wall will not produce any bleeding.
  2. The total separation of the client's placenta from the uterine wall will lead to massive hemorrhage.
  3. Blood is trapped between the client's placenta and the uterine wall, and there may be concealed bleeding.
  4. Blood is passing between the fetal membranes and the client's uterine wall, which will lead to some vaginal bleeding.

[diesoon]

Answer to Question 1

3
Explanation:
1. Preeclampsia is not diagnosed until the 20th week of gestation.
This client is only at 18 weeks. Further, blood pressure can be assessed in either arm when the client is in a sitting position; in a side-lying position, the blood pressure should be assessed in the upper arm.
2. Preterm labor is not diagnosed until 20 weeks. This client is only at 18 weeks. Fetal fibronectin (fFN) testing is not indicated at this time.
3. A diet containing 3500 kcal (minimum) and 175 g protein is recommended for a client with normal-weight twins. Teaching about protein sources facilitates adequate fetal growth.
4. Although the incidence of multifetal pregnancy is higher in pregnancies resulting from infertility treatment than in those that are spontaneous pregnancies, the cause of the multifetal pregnancy does not impact nursing care.

Answer to Question 2

3
Explanation:
1. This describes a marginal placenta separation, grade 1.
2. With complete separation, there is total separation of the placenta from the uterine wall, and massive bleeding ensues.
3. With the central type of placental separation, blood is trapped between the placenta and uterine wall with concealed bleeding.
4. This describes a marginal placenta separation, grade 1.