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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)?

A.

Weight gain of 2 pounds (0.91 kg).

B.

1+ edema on her lower extremities.

C.

Fundal height of 30 cm.

D.

Fetal heart rate of 110 beats/minute.

Answer and Explanation

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.

 


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Related Questions

Correct Answer is A

Explanation

Choice A rationale

Checking serum human chorionic gonadotropin (hCG) levels is the appropriate action. hCG levels can help determine the viability of the pregnancy. Decreasing hCG levels may indicate a non-viable pregnancy, while increasing levels suggest a viable pregnancy.

Choice B rationale

Verifying the date of the last menstrual cycle is important but not the priority action in this scenario. While it can provide information on gestational age, it does not directly address the concern of vaginal bleeding.

Choice C rationale

Inquiring about the last occurrence of intercourse is not directly related to assessing the cause of vaginal bleeding. It may provide additional history but does not address the immediate concern.

Choice D rationale

Repeating a urine pregnancy test is not necessary in this context. The client is already known to be pregnant, and a urine test will not provide additional information regarding the cause of the bleeding.

Correct Answer is B

Explanation

Choice A rationale

Diet cola, although refreshing, contains caffeine which can contribute to dehydration. For adolescents with sickle cell anemia, hydration is crucial to prevent sickle cell crises. Moreover, sodas generally offer no nutritional benefits.

Choice B rationale

Lemonade is a better choice as it is hydrating and provides fluids without caffeine. Proper hydration is vital for sickle cell patients to maintain blood volume and prevent the sickling of red blood cells. Additionally, lemonade can supply essential electrolytes.

Choice C rationale

Ice tea, similar to diet cola, contains caffeine which can exacerbate dehydration. Hydration is key for individuals with sickle cell anemia to avoid complications and maintain adequate blood flow.

Choice D rationale

Milkshake, while providing hydration, is high in fat and sugar, which can be counterproductive. It also lacks the electrolytes present in lemonade which are beneficial for maintaining fluid balance in the body.

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