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 B
Explanation
Choice A rationale
Shallow and irregular respirations are normal for newborns and do not typically indicate respiratory distress. Regular assessment is necessary to determine if there is an underlying issue.
Choice B rationale
Flaring of the nares is a sign of increased effort to breathe and is an indication of respiratory distress in newborns. This symptom requires immediate attention to address potential underlying conditions.
Choice C rationale
Abdominal breathing with synchronous chest movement is normal in newborns due to their diaphragmatic breathing pattern. It does not indicate respiratory distress unless other symptoms are present.
Choice D rationale
A respiratory rate of 50 breaths per minute is within the normal range for newborns (30-60 breaths per minute). This does not indicate respiratory distress unless accompanied by other abnormal signs.
Correct Answer is C
Explanation
Choice A rationale
Administering the rubella vaccine after 20-weeks gestation is inappropriate as it is a live vaccine, which poses potential risks to the fetus. The vaccine is contraindicated during pregnancy due to teratogenic effects.
Choice B rationale
Administering the rubella vaccine at 6-weeks gestation is contraindicated because it is a live vaccine. Live vaccines pose risks to the fetus and are not recommended during pregnancy due to potential teratogenicity.
Choice C rationale
Administering the rubella vaccine early postpartum within 72 hours after delivery is recommended. This timing ensures the mother is not pregnant and reduces the risk of congenital rubella syndrome in future pregnancies.
Choice D rationale
Waiting until the client stops breastfeeding is unnecessary. The rubella vaccine can be safely administered during breastfeeding, as it does not pose a risk to the infant or affect milk production.
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