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.

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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Correct Answer is D

Explanation

Choice A rationale

Iron is essential for preventing anemia, particularly in pregnant women, but it does not prevent neural tube defects like anencephaly. Iron supports overall maternal and fetal health but is not specific to preventing congenital anomalies.

Choice B rationale

Calcium is crucial for fetal bone development and maternal bone health, but it does not play a role in preventing anencephaly. Adequate calcium intake is important during pregnancy but is not linked to neural tube defect prevention.

Choice C rationale

Vitamin D is important for bone health and immune function but does not prevent neural tube defects. Sufficient vitamin D levels are necessary for the mother's and baby's health but are not related to anencephaly prevention.

Choice D rationale

Folic acid is the correct choice as it has been shown to prevent neural tube defects, including anencephaly and spina bifida. It is recommended that women of childbearing age take folic acid supplements before conception and during early pregnancy to reduce the risk of these congenital anomalies.

A. Stops rooting when hungry. B. Opens mouth when food comes her way. C. Awakens once for nighttime feedings. D. Gives up a bottle for a cup.

Correct Answer is B

Explanation

Choice A rationale

Rooting is a reflex that helps a baby find and latch onto the breast or bottle for feeding. While the rooting reflex may diminish as the baby grows, it is not the primary indicator for introducing solid foods. Other developmental milestones are more relevant for this transition.

Choice B rationale

When a baby starts opening their mouth in response to the sight or smell of food, it indicates a readiness to try solid foods. This behavior shows that the baby is interested in and capable of learning to eat from a spoon, which is a key step in the introduction of solids.

Choice C rationale

Awakening once for nighttime feedings is common for infants and does not necessarily indicate readiness for solid foods. Nighttime awakenings can occur for various reasons, including hunger, but other developmental signs should be considered for introducing solids.

Choice D rationale

Giving up a bottle for a cup is a milestone that typically occurs later in infancy or toddlerhood. It is not directly related to the introduction of solid foods, which generally begins around 4 to 6 months of age based on the child's developmental readiness and interest in food.

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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)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing preconception counseling. Which supplement should the nurse recommend to help prevent the occurrence of anencephaly?

Correct Answer is D

Explanation

The mother of a 4-month-old baby girl asks the nurse when she should introduce solid foods to her infant.The mother states, "My mother says I should put rice cereal in the baby's bottle now.”. The nurse should instruct the mother to introduce solid foods when her child exhibits which behavior?

Correct Answer is B

Explanation

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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)?