A low-risk primigravida at 28-weeks gestation arrives for her regular antepartal clinic visit. Which assessment finding should the nurse consider within normal limits for this client?

Proteinuria.

Pulse increase of 10 beats/minute.

Glucosuria.

Fundal height of 22 cm.

Answer and Explanation

The Correct Answer is B

A. Proteinuria is not normal in pregnancy. The presence of protein in the urine may indicate kidney involvement or preeclampsia, which requires further evaluation. Any persistent proteinuria should be investigated promptly.

B. A pulse increase of 10 beats per minute is within normal physiological changes in pregnancy. During the second and third trimesters, maternal heart rate normally increases by 10–20 beats per minute to accommodate the increased cardiac output needed for the growing fetus. This is an expected adaptation and considered normal.

C. Glucosuria is not typically normal and may indicate impaired glucose tolerance or gestational diabetes. While small amounts of glucose can occasionally appear in urine, consistent glucosuria should prompt further assessment.

D. A fundal height of 22 cm at 28 weeks is below the expected range. Fundal height in centimeters roughly corresponds to gestational age in weeks after 20 weeks, so at 28 weeks, a normal fundal height would be approximately 26–30 cm. A measurement of 22 cm may indicate intrauterine growth restriction or inaccurate measurement and should be evaluated.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Giving carbonated drinks is inappropriate after gastric bypass surgery. Carbonation can increase gas, bloating, and discomfort, and may stress the surgically altered stomach. Assessing hydration is important, but offering carbonated beverages is unsafe.

B. Assessing vital signs and reporting the finding to the healthcare provider immediately is the most appropriate action. Abdominal distention early after gastric bypass may indicate postoperative complications such as bowel obstruction, internal hernia, or ileus, which can become life-threatening if not addressed promptly. Vital signs help identify early signs of shock or sepsis, such as hypotension or tachycardia, guiding timely intervention.

C. Measuring the abdomen and reviewing dietary intake is part of routine postoperative care, but it does not address the urgency of possible surgical complications. Delaying provider notification could worsen outcomes.

D. While ambulation helps prevent gas formation in stable postoperative patients, encouraging walking without assessing for serious complications is unsafe in the presence of sudden abdominal distention.

A. Roasted turkey, canned vegetables. B. Baked potato with skin, raw carrots. C. Roast pork, fresh strawberries. D. Pancakes, whole-grain cereals.

Correct Answer is A

Explanation

A. Roasted turkey and canned vegetables are correct selections for a low-fiber diet. Low-fiber diets are designed to reduce the amount of undigested material passing through the gastrointestinal tract, which helps minimize irritation and symptoms in clients with ulcerative colitis. Canned vegetables have lower fiber content than raw vegetables, and lean meats like turkey are naturally low in fiber, making this combination appropriate for the prescribed diet.

B. A baked potato with skin and raw carrots are incorrect because both contain significant amounts of insoluble fiber. The skin of the potato and the raw carrots could increase intestinal bulk and irritation, which is contraindicated for a low-fiber diet during active ulcerative colitis management.

C. Roast pork is appropriate as it is low in fiber, but fresh strawberries are high in fiber and contain small seeds, which can exacerbate gastrointestinal symptoms. This selection reflects a misunderstanding of which fruits are suitable for a low-fiber diet.

D. Pancakes and whole-grain cereals are incorrect because whole grains are high in fiber. While pancakes made from refined flour are low in fiber, pairing them with whole-grain cereals increases fiber intake, making this combination inconsistent with a low-fiber diet.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A low-risk primigravida at 28-weeks gestation arrives for her regular antepartal clinic visit. Which assessment finding should the nurse consider within normal limits for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An adult client who had a gastric bypass two days ago reports to the nurse of feeling bloated. After verifying that the client's abdomen is distended, which intervention should the nurse implement?

Correct Answer is B

Explanation

The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection indicates to the nurse that the client understands the prescribed diet?

Correct Answer is A

Explanation

The nurse is providing education to a client and family on hospice. Which information should the nurse provide about hospice care?

The nurse is conducting a visual screening of a group of older adults. Which finding should the nurse report to the healthcare provider immediately?

The healthcare provider prescribes a liter of normal saline to be infused at a rate of 1.5 mL/kg/hr. The client weighs 176 pounds. The nurse should set the infusion pump to deliver how many mL/hr? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the nurse delegate to the UAP?

A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure?

Which environmental factor is most significant when planning care for a client with osteomalacia?

An older adult client is taken to the clinic by the spouse, who appears extremely worried. The spouse reports to the nurse that the client started to not make any sense and asked to visit a brother that has been dead for many years. Which action(s) should the nurse take? Select all that apply.