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 ["25"]

Explanation

Step 1: Calculate the total daily dose in mg: 25 kg × 10 mg/kg/day = 250 mg/day.

Step 2: Determine how many mL are needed to administer the 250 mg dose: (250 mg ÷ 50 mg) × 5 mL = (5) × 5 mL = 25 mL. Final calculated answer: 25 mL.v

A. Offer a pacifier for non-nutritive sucking. B. Use sterile technique during feedings. C. Ensure placement of the nasogastric tube with an abdominal x-ray. D. Speak to the healthcare provider about instituting physical therapy.

Correct Answer is A

Explanation

Choice A rationale

Non-nutritive sucking, such as with a pacifier, can be soothing and calming for infants. It helps in the development of oral motor skills and provides comfort during enteral feedings, ensuring that the infant’s need for sucking is met even when they are not feeding.

Choice B rationale

Sterile technique is essential for preventing infections during invasive procedures, but enteral feeding typically does not require such stringent measures. Clean technique is usually sufficient unless the infant has a compromised immune system or other specific medical conditions requiring sterile precautions.

Choice C rationale

While verifying tube placement is critical, it is often done using methods such as pH testing of gastric contents or external marking rather than routine x-rays. Overuse of x-rays exposes infants to unnecessary radiation. X-rays are used primarily when other methods are inconclusive.

Choice D rationale

Instituting physical therapy for a one-month-old infant would not be developmentally appropriate as their primary needs are centered around nutrition, comfort, and growth. Physical therapy is more relevant for older children with developmental or mobility issues rather than infants receiving enteral feedings. .

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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

A child who weighs 25 kg receives a prescription for isoniazid 10 mg/kg/day by mouth once a day. The bottle is labeled "isoniazid Oral Solution, USP 50 mg per 5 mL.”. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

Correct Answer is ["25"]

Explanation

A one-month-old infant admitted to the hospital with dehydration and failure to thrive receives a prescription for enteral feedings. To maintain normal growth and development of the infant, which action should the nurse include?

Correct Answer is A

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)?