A nurse in a clinic is preparing to measure the fundal height of a client who is pregnant. Which of the following actions should the nurse take?

Lay the tape measure horizontally over the middle of the client's abdomen.

Place the client in a left-lateral position to obtain the measurement.

Measure from the upper border of the symphysis pubis to the upper border of the fundus

Ensure that the client has a full bladder before taking the measurement.

Answer and Explanation

The Correct Answer is C

A. The tape measure should be placed vertically, not horizontally, over the abdomen to measure fundal height accurately.
B. The client should be in a supine position, not left-lateral, during the measurement.
C. Fundal height is measured from the upper border of the symphysis pubis to the upper border of the uterine fundus.
D. A full bladder can distort the measurement, so the client should have an empty bladder before measuring fundal height.

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Correct Answer is D

Explanation

A. Fentanyl citrate is a potent opioid, typically reserved for severe pain and usually administered in controlled settings, not first-line postpartum analgesia.
B. Meperidine is less commonly used due to side effects and safety concerns.
C. Aspirin is generally avoided postpartum due to bleeding risks.
D. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) commonly used postpartum for pain relief and inflammation control with a safer profile for breastfeeding mothers.

A. Give ondansetron IV to the client. B. Administer IV fluid bolus to the client. C. Delay the epidural until the client is dilated to 7 cm. D. Initiate oxygen via nonrebreather to support patterned breathing

Correct Answer is B

Explanation

A. Ondansetron is used to treat nausea but is not a routine pre-epidural intervention.
B. Administering an IV fluid bolus before epidural anesthesia helps prevent hypotension caused by sympathetic blockade.
C. Epidurals can be administered earlier than 7 cm dilation based on maternal request and clinical assessment.
D. Oxygen administration is not routinely required before an epidural unless fetal distress or maternal hypoxia is present.

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A nurse in a clinic is preparing to measure the fundal height of a client who is pregnant. Which of the following actions should the nurse take?

Nursing Test Bank

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