A 34-week gestation multigravida comes to the clinic for her bimonthly appointment.
Which assessment finding should the nurse report to the healthcare provider (HCP)?
Weight gain of 2 pounds (0.91 kg).
1+ edema on her lower extremities.
Fundal height of 30 cm.
Fetal heart rate of 110 beats/minute.
The Correct Answer is C
Choice A rationale
A weight gain of 2 pounds (0.91 kg) in a 34-week gestation multigravida is generally considered normal. During the third trimester, it is typical for a pregnant woman to gain around 0.5 to 1 pound per week. This weight gain helps support the growing fetus and prepare the mother's body for labor and breastfeeding. However, sudden or excessive weight gain could indicate fluid retention or preeclampsia, but a 2-pound gain alone is not necessarily a concern.
Choice B rationale
1+ edema on the lower extremities is a common finding during pregnancy, especially in the later stages. It is usually due to increased blood volume and pressure on the pelvic veins from the growing uterus, which can slow the return of blood from the legs. While some degree of edema is normal, particularly in the ankles and feet, it is important to monitor for sudden or severe swelling, which could be a sign of preeclampsia.
Choice C rationale
A fundal height of 30 cm at 34 weeks gestation is concerning because it is less than the expected measurement. Fundal height typically corresponds to gestational age in centimeters (±2 cm). Therefore, at 34 weeks, the expected fundal height would be between 32 and 36 cm. A smaller fundal height could indicate intrauterine growth restriction (IUGR), oligohydramnios, or other fetal development issues, which require further evaluation by the healthcare provider.
Choice D rationale
A fetal heart rate (FHR) of 110 beats per minute (bpm) is within the normal range for a fetus. The normal FHR typically ranges from 110 to 160 bpm. Although 110 bpm is on the lower end of the normal range, it is still considered acceptable. Significant deviations from the normal range, either too low (bradycardia) or too high (tachycardia), could indicate fetal distress and require immediate attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While increasing protein intake is beneficial for overall health and pregnancy, it is not the primary factor that affects hemoglobin and hematocrit levels. These levels are more directly influenced by iron intake and the physiological changes during pregnancy. Protein intake is important for fetal growth and development, but it does not significantly alter the concentration of hemoglobin or hematocrit in the blood.
Choice B rationale
During pregnancy, plasma volume increases by approximately 50%, leading to hemodilution. This means that even though the total number of red blood cells increases, the concentration of hemoglobin and hematocrit appears lower due to the larger volume of plasma. This physiological change helps meet the increased oxygen demands of both the mother and the growing fetus and is a normal part of pregnancy.
Choice C rationale
Taking an iron supplement can help improve hemoglobin and hematocrit levels, especially if a pregnant woman has iron-deficiency anemia. Iron is essential for the production of hemoglobin, which carries oxygen in the blood. However, not all pregnant women with lower hemoglobin and hematocrit levels need to take iron supplements, as these values can be within the expected range for pregnancy. The decision to supplement should be based on individual assessment by a healthcare provider.
Choice D rationale
Not all women at 28 weeks gestation have anemia. While it is common for hemoglobin and hematocrit levels to be lower during pregnancy due to increased plasma volume, it does not mean that all pregnant women are anemic. Anemia is diagnosed based on specific thresholds for hemoglobin and hematocrit levels, and the values mentioned (hemoglobin 10.7 g/dL and hematocrit 32%) are borderline and may not necessarily indicate anemia.
Correct Answer is A
Explanation
Choice A rationale
Giving zidovudine 6 to 12 hours after birth is crucial as it helps prevent mother-to-child transmission of HIV. Early administration of antiretroviral medication reduces the risk of the newborn acquiring HIV significantly.
Choice B rationale
Administering antibiotics for 7 to 10 days is not standard practice for newborns of HIV-positive mothers unless there is an indication of infection. The primary intervention is antiretroviral therapy.
Choice C rationale
Delaying the initial bath for 1 to 2 days is not standard practice for preventing HIV transmission. It is important to bathe the newborn shortly after birth to remove any potential HIV-containing fluids.
Choice D rationale
Encouraging breastfeeding every 2 to 3 hours is not advised for HIV-positive mothers as HIV can be transmitted through breast milk. Alternatives such as formula feeding are recommended to prevent transmission. .
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