In assessing a primigravida woman at 15 weeks gestation by dates, the nurse palpates the fundus at the umbilicus. Based on this assessment finding, it is most important for the nurse to obtain information about the occurrence of which condition?

Urinary frequency.

Lightening.

Fetal movement.

Braxton-Hicks contractions.

Answer and Explanation

The Correct Answer is C

A. Urinary frequency: Urinary frequency is common during pregnancy due to increased pressure on the bladder from the growing uterus. However, it is not directly related to fundal height assessment.

B. Lightening: Lightening is the descent of the baby's head into the pelvis, which typically occurs in the third trimester, not at 15 weeks.

C. Fetal movement: Fetal Movement is an appropriate choice because it directly relates to determining the presence of a viable fetus. This information can assist in ruling out a complete molar pregnancy, where no fetal movement would be expected. It can guide the nurse to investigate further, potentially leading to more specific diagnostic procedures such as an ultrasound to confirm the underlying cause of the abnormal fundal height.

D. Braxton-Hicks contractions: Braxton-Hicks contractions can occur throughout pregnancy, but they are not a cause for concern at 15 weeks.

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Correct Answer is D

Explanation

A. Decrease in the appetite. While a decreased appetite can contribute to malnutrition, it is a symptom rather than a definitive indicator of the current nutritional status. Other factors can lead to decreased appetite, and it does not directly quantify malnutrition.

B. Weight of 227 lb (103 kg). This weight alone does not provide information about malnutrition. Without knowing the client's height, the BMI, or body composition, this information is not useful for diagnosing malnutrition.

C. Dry mucosal membranes. Dry mucosal membranes can be a sign of dehydration or other conditions but are not specific to malnutrition.

D. Body mass index (BMI) of 17 kg/m².A BMI of 17 kg/m² is below the normal range (18.5 to 24.9 kg/m²) and directly indicates undernutrition, supporting the diagnosis of malnutrition.

A. Inspection. B. Auscultation. C. Palpation. D. Percussion.

Correct Answer is A

Explanation

A. Inspection. Papilledema, swelling of the optic disc due to increased intracranial pressure, is primarily assessed through inspection of the optic disc using an ophthalmoscope. The nurse would look for optic disc swelling and blurred disc margins.

B. Auscultation. Auscultation is not appropriate for assessing papilledema, as it involves listening for sounds such as heart, lung, or bowel sounds.

C. Palpation. Palpation is not appropriate for assessing papilledema, as it involves touching and feeling for abnormalities, which would not be possible with the optic disc.

D. Percussion. Percussion is not appropriate for assessing papilledema, as it involves tapping the body surface to elicit sounds or vibrations, which would not provide information about the optic disc.

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In assessing a primigravida woman at 15 weeks gestation by dates, the nurse palpates the fundus at the umbilicus. Based on this assessment finding, it is most important for the nurse to obtain information about the occurrence of which condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has been diagnosed with malnutrition. Which finding supports the medical diagnosis?Reference Range: Body Mass Index (BMI) (18.5 to 24.9 kg/m3]

Correct Answer is D

Explanation

Which assessment technique should the nurse use to confirm the presence of papilledema in a client with a rapidly decreasing level of consciousness?

Correct Answer is A

Explanation

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