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
A blood glucose level should be obtained first to determine if hypoglycemia is the cause of the infant's jitteriness, which is common in large-for-gestational-age infants of diabetic mothers.
Choice B rationale
Feeding glucose water might help if the infant is hypoglycemic, but confirmation of blood glucose levels is necessary before administration to avoid hyperglycemia.
Choice C rationale
Administering oxygen is indicated if there are signs of respiratory distress or cyanosis, which is not the first consideration in a jittery infant.
Choice D rationale
Decreasing environmental stimuli can be helpful for a jittery infant, but assessing and managing potential hypoglycemia is the priority action.
Correct Answer is C
Explanation
Choice A rationale
Increasing IV infusion rate can exacerbate fluid overload and hypertension, potentially worsening the patient's condition. Monitoring fluid status and adjusting infusions cautiously is critical to avoid iatrogenic complications.
Choice B rationale
Assessing vital signs helps detect early signs of complications such as hypovolemia, infection, or abnormal bleeding, facilitating timely intervention to prevent further deterioration.
Choice C rationale
Massaging the fundus promotes uterine contraction, reducing the risk of postpartum hemorrhage. Effective fundal massage can control bleeding and stabilize the patient following childbirth.
Choice D rationale
Notifying the healthcare provider ensures prompt communication of any changes in the patient's condition, enabling timely medical intervention and potentially preventing adverse outcomes.
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