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.
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.
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