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 ["B","E"]

Explanation

A. Maternal Rh factor – The mother is O positive. Rh incompatibility is not a concern here because both mother and newborn are likely Rh positive, and no information suggests Rh incompatibility.
B. Gestational age – The newborn was born at 36 weeks and 4 days, which is considered late preterm and places the infant at increased risk for complications such as respiratory distress, jaundice, hypoglycemia, and feeding difficulties.
C. Apgar scores – Scores of 7 at 1 minute and 8 at 5 minutes are within the normal range and not indicative of distress or a complication risk.
D. Weight – A birth weight of 3,062 g (6 lb 12 oz) is appropriate for gestational age and not a risk factor.
E. Type of birth – Operative vaginal birth using a vacuum extractor increases the risk for complications like cephalohematoma, which is noted in the assessment (firm, edematous scalp area with ecchymosis not crossing suture lines). This can contribute to jaundice.
F. Length – A length of 48 cm (19 in) is appropriate for gestational age and not a risk factor.

A. Cervical dilation B. Uterine contractions C. Vaginal bleeding D. Client reports low back pain E. Abdominal tenderness

Correct Answer is {"A":{"answers":"B,C"},"B":{"answers":"B,C"},"C":{"answers":"A,C"},"D":{"answers":"B,C"},"E":{"answers":"C"}}

Explanation

Assessment findings	Placenta previa	Preterm labor	Abruption placenta
Cervical dilation		✓	✓
Uterine contractions		✓	✓
Vaginal bleeding	✓		✓
Client reports low back pain		✓	✓
Abdominal tenderness			✓

Rationale

Cervical dilation: Present in preterm labor and abruption due to uterine activity and cervical changes; not typical in placenta previa unless labor begins.
Uterine contractions: Present in preterm labor and abruption; placenta previa usually painless without contractions.
Vaginal bleeding: In placenta previa, bleeding is usually painless; in abruption, bleeding is often accompanied by pain; preterm labor usually does not involve bleeding.
Low back pain: Common in preterm labor and abruption due to contractions or placental separation; not typical in placenta previa.
Abdominal tenderness: Present in abruption because of bleeding behind the placenta causing uterine irritation; absent in placenta previa and preterm labor.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn Exhibits Which findings are risk factors for the newborn to develop a complication? Select all that apply

Correct Answer is ["B","E"]

Explanation

Correct Answer is {"A":{"answers":"B,C"},"B":{"answers":"B,C"},"C":{"answers":"A,C"},"D":{"answers":"B,C"},"E":{"answers":"C"}}

Explanation

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