A nurse is about to measure the fundal height of a patient who is 22 weeks pregnant.
Where should the nurse anticipate feeling the fundus?
3 cm above the umbilicus.
3 cm below the umbilicus.
Slightly below the umbilicus.
Slightly above the umbilicus.
The Correct Answer is D
The correct answer is D. Slightly above the umbilicus. At about 20 weeks of pregnancy, the fundus of the uterus is usually at the level of the umbilicus. By 22 weeks, the fundus is typically slightly above the umbilicus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The nurse should include in the teaching that a client who is 23 weeks pregnant can receive an influenza vaccination during pregnancy. This is because the influenza vaccine is safe and recommended for pregnant women to protect both the mother and the baby from the flu.
Choice B rationale
The rubella vaccine is a live vaccine and is not recommended during pregnancy or while breastfeeding due to the potential risk to the baby. However, it can be given immediately after delivery if the woman is not immune.
Choice C rationale
The varicella vaccine is also a live vaccine and is not recommended during pregnancy. It should be given before pregnancy or immediately after delivery if the woman is not immune.
Choice D rationale
The Tdap (Tetanus, Diphtheria, Pertussis) vaccine is actually recommended during each pregnancy, regardless of the patient’s previous history of receiving the vaccine. The optimal timing for Tdap administration is between 27 and 36 weeks of gestation.
Correct Answer is A
Explanation
Choice A rationale
Maintain the patient on bed rest. This is a common nursing intervention for a patient who is experiencing an inevitable abortion. Bed rest can help reduce the risk of further complications, such as heavy bleeding. It can also provide the patient with a chance to rest and recover physically and emotionally.
Choice B rationale
Offer the option to view products of conception. This intervention may not be appropriate for all patients. While some patients may find it helpful to view the products of conception, others may find it distressing. It’s important to discuss this option with the patient and respect her wishes.
Choice C rationale
Administer oxygen via a nasal cannula. This intervention may not be necessary for all patients experiencing an inevitable abortion. While oxygen therapy can be used to treat hypoxia in patients with heavy bleeding, it’s not typically required unless the patient shows signs of hypoxia.
Choice D rationale
Instruct the patient to increase potassium-rich foods in the diet. This intervention is not typically part of the care plan for a patient experiencing an inevitable abortion. While a balanced diet is important for overall health, there’s no specific need to increase potassium-rich foods in the diet in this situation.
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