At 20-weeks gestation, a client who has gained 20 pounds (9.1 kg) during this pregnancy tells the nurse that she is feeling fetal movement.
Fundal height measurement is 20 cm, and the client’s only complaint is that her breasts are leaking clear fluid. Which assessment finding warrants further evaluation?
Leakage from breasts.
Gestational weight gain.
Presence of fetal movement.
Fundal height measurement.
The Correct Answer is B
Choice A rationale
Leakage of clear fluid from the breasts towards the end of the second trimester into the third trimester is normal. This fluid is colostrum, a precursor to breastmilk, and its presence indicates breast development in preparation for lactation.
Choice B rationale
An average weight gain during pregnancy is 25 to 35 pounds. In the second trimester, a woman should be gaining about 1 pound per week. A weight gain of 20 pounds by 20 weeks indicates the client is on track or has even gained slightly more than expected. However, further evaluation is important as excessive weight gain in pregnancy might be indicative of underlying conditions such as preeclampsia or gestational diabetes.
Choice C rationale
Fetal movement, also known as quickening, is a normal and expected occurrence around 18-20 weeks' gestation. It is a positive sign of fetal development and well-being.
Choice D rationale
Fundal height is the measure from the pubic symphysis to the top of the uterus. It is an indicator of fetal growth. A fundal height of 20cm at 20 weeks gestation suggests the pregnancy is progressing normally and the baby is growing appropriately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While increasing caloric intake can be beneficial for breastfeeding mothers, it does not directly address the client’s concern about decreased insulin needs.
Choice B rationale
Advising the client to breastfeed more frequently does not directly address the client’s concern about decreased insulin needs.
Choice C rationale
Breastfeeding can lead to a decreased need for insulin in some individuals. This is because lactation requires energy, and this energy demand can affect the mother’s insulin requirements.
Choice D rationale
While scheduling an appointment with the diabetic nurse educator can be helpful, it is not the immediate response to the client’s concern about decreased insulin needs.
Correct Answer is B
Explanation
Choice A rationale
Poor appetite can be a symptom of many neonatal conditions, but it's not the most common complication specifically associated with cephalhematoma.
Choice B rationale
Cephalhematomas are caused by the rupture of blood vessels between the skull and periosteum, resulting in a blood collection. The breakdown of red blood cells in this trapped blood can lead to the release of bilirubin, increasing an infant's risk for hyperbilirubinemia and jaundice.
Choice C rationale
Hypoglycemia is a potential concern in neonates but is not directly related to cephalhematoma.
Choice D rationale
While brain damage is a serious potential complication in cases of severe skull trauma, it's not typically associated with cephalhematoma alone. Cephalhematomas usually resolve on their own without long-term consequences.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.