The home health nurse is admitting a patient at 18 weeks who is pregnant with twins. Which nursing action is most important?

Question

1. Teach the patient about foods that are good sources of protein.
2. Assess the patient's blood pressure in her upper right arm.
3. Determine whether the pregnancy is a result of infertility treatment.
4. Collect a cervicovaginal fetal fibronectin (fFN) specimen.

Answer 1

Correct Answer: 1
Rationale 1: A diet containing 3,500 kcal (minimum) and 175 g protein is recommended for a woman with normal-weight twins. Teaching about protein sources facilitates adequate fetal growth.
Rationale 2: Pre-eclampsia is not diagnosed until the 20th week of gestation. This patient is only at 18 weeks. Further, blood pressure can be assessed in either arm when the patient is in a sitting position; in a side-lying position, the blood pressure should be assessed in the upper arm.
Rationale 3: Although the incidence of multifetal pregnancy is higher in pregnancies resulting from infertility treatment than in those resulting from spontaneous pregnancies, the cause of the multifetal pregnancy does not impact nursing care.
Rationale 4: Preterm labor is not diagnosed until 20 weeks. This patient is only at 18 weeks. Fetal fibronectin (fFN) testing is not indicated at this time.