A 26-week gestational primigravida who is carrying twins is seen in the clinic today. Her fundal height is measured at 29 cm. Based on these findings, which action should the nurse implement?
Document the finding in the medical record.
Schedule the client for a biophysical profile.
Request another nurse measure the fundus.
Notify the healthcare provider of the finding.
The Correct Answer is B
Choice A rationale
Documenting the finding in the medical record is routine, but it does not address the potential concern of the fundal height discrepancy, which may indicate a need for further evaluation.
Choice B rationale
Scheduling a biophysical profile is crucial to assess the well-being of the fetuses, especially given the discrepancy in fundal height, which could indicate issues such as growth restriction or polyhydramnios.
Choice C rationale
Requesting another nurse to measure the fundus might help verify the measurement but does not address the potential underlying issue, which requires further assessment like a biophysical profile.
Choice D rationale
Notifying the healthcare provider is necessary, but it is more appropriate to first schedule a biophysical profile to gather comprehensive information on the fetal well-being before consulting the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
SROM for 36 hours before delivery significantly increases the risk of postpartum endometritis due to prolonged exposure of the uterine cavity to potential pathogens. Prompt antibiotic therapy may be required to prevent infection.
Choice B rationale
Labor lasting for 24 hours can contribute to maternal fatigue and increased risk of complications, but it is not the primary factor for postpartum endometritis. The duration of rupture of membranes is more critical in this context.
Choice C rationale
A third-degree perineal laceration poses a risk for infection at the wound site but is not the leading cause of postpartum endometritis. The primary concern remains the extended duration of ruptured membranes.
Choice D rationale
Epidural anesthesia is not directly associated with an increased risk of postpartum endometritis. Its primary effects are related to pain management and potential impacts on labor progression, not infection risk.
Correct Answer is ["A","B","D","E"]
Explanation
Choice A rationale
Acidemia in the fetus can result from abnormal fetal heart rate (FHR) patterns. It is indicative of hypoxia and inadequate oxygenation, leading to anaerobic metabolism and accumulation of lactic acid in fetal tissues.
Choice B rationale
Hypoxia can occur due to abnormal FHR patterns. Hypoxia results from insufficient oxygen supply to the fetus, which can lead to metabolic acidosis, impaired organ function, and potential long-term developmental issues.
Choice C rationale
Hypoglycemia is not directly related to abnormal FHR patterns. It is primarily associated with metabolic disturbances such as inadequate glucose supply or insulin regulation in the neonate or fetus.
Choice D rationale
Meconium stool passage can result from fetal hypoxia due to abnormal FHR patterns. Hypoxia increases gastrointestinal peristalsis, leading to the release of meconium into the amniotic fluid, which poses a risk for aspiration.
Choice E rationale
Maternal hypotension can lead to abnormal FHR patterns. Hypotension reduces uteroplacental blood flow, leading to fetal hypoxia and compromised oxygen delivery to the fetus, which can result in fetal distress.
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