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. "Would you like to talk about what is bothering you?" B. "Do you feel like practicing insulin injections now?" C. "I know you are afraid, but I am here to help you." D. "Before you can go home you must learn how to give insulin."

Correct Answer is A

Explanation

A. "Would you like to talk about what is bothering you?" This empathetic approach acknowledges the client's emotional state and opens the door for them to express their concerns, which might be related to the diagnosis, fear of injections, or other anxieties.

B. "Do you feel like practicing insulin injections now?" This disregards the client's emotional state and might be perceived as insensitive.

C. "I know you are afraid, but I am here to help you." While offering reassurance, it assumes the client's fear without allowing them to express their emotions.

D. "Before you can go home you must learn how to give insulin." This is a directive and doesn't address the client's emotional response. It's important to prioritize addressing their concerns before proceeding with teaching.

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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

The nurse plans to teach a client newly diagnosed with diabetes mellitus how to inject insulin. Upon entering the room with the injection supplies, the nurse finds the client in tears. How should the nurse respond?

Correct Answer is A

Explanation

A client has a prescription for vital sign measurement every four hours. The nurse observes that the client's blood pressure has increased from 140/60 mm Hg at noon to 180/90 mm Hg four hours later. Which action should the nurse implement?

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