The nurse is assessing the abdomen of a woman who is eight months pregnant. Which characteristic is the nurse likely to observe? Select all that apply.

Fetal movement

Linea nigra

Striae

Vernix caseosa

Scaphoid profile

Answer and Explanation

Correct Answer : A,B,C

A. Fetal movement: By the eighth month of gestation, the fetus has developed sufficient muscular coordination and size for its activity to be visible through the maternal abdominal wall. These movements indicate fetal well-being and are a hallmark of late-stage pregnancy assessment. The nurse can often palpate or observe these shifts during the physical examination.

B. Linea nigra: This is a hyperpigmented linear streak extending from the symphysis pubis to the top of the fundus, caused by increased melanocyte-stimulating hormone. It is a common physiological integumentary change that occurs during the second and third trimesters. It typically resolves postpartum but is a prominent feature in late pregnancy.

C. Striae: Also known as striae gravidarum or stretch marks, these are linear jagged scars resulting from the rapid expansion of the abdomen and hormonal changes. They appear as pink, silver, or purple indents in the skin where dermal collagen has stretched. They are highly prevalent in the third trimester as the uterus reaches maximum distension.

D. Vernix caseosa: This is a thick, white, sebaceous substance that coats the skin of the fetus in utero to provide protection and lubrication. While it is present on the fetus, it is not an observable characteristic of the maternal abdomen during an external assessment. It only becomes visible to the nurse upon delivery of the neonate.

E. Scaphoid profile: A scaphoid abdomen is characterized by a concave or sunken appearance where the anterior wall is recessed. This is anatomically impossible in the eighth month of pregnancy due to the large, gravid uterus displacing the abdominal contents forward. A pregnant abdomen at this stage is protuberant or globular.

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Correct Answer is ["A","B","D"]

Explanation

A. Lower resistance to infections: Protein-energy malnutrition impairs the production of leukocytes and immunoglobulins essential for the immune response. Depleted micronutrients like zinc and vitamin C further compromise mucosal barriers and cellular immunity. This increases the host's susceptibility to opportunistic and pathogenic microbes.

B. Delayed wound healing: Tissue repair requires adequate stores of amino acids, vitamins, and minerals to synthesize collagen and new cells. Without sufficient nutritional reserves, the inflammatory and proliferative phases of healing are significantly prolonged. This increases the risk of wound dehiscence and chronic ulceration.

C. Gallbladder disease: This condition is more frequently associated with obesity, rapid weight loss, or high-fat diets rather than depleted reserves. While malnutrition can lead to biliary stasis, it is not a primary or common hallmark of generalized undernutrition. Other systemic failures take precedence in depleted states.

D. Impaired growth & development: Adequate caloric and nutrient intake is mandatory for the physiological processes of hypertrophy and hyperplasia during maturation. Nutritional deficits disrupt the endocrine signals and structural building blocks required for skeletal and cognitive advancement. This often results in stunting or developmental delays.

E. Type II diabetes: This metabolic disorder is primarily characterized by insulin resistance and is strongly linked to overnutrition and adiposity. Depleted nutritional reserves usually correlate with increased insulin sensitivity or low glycemic levels. It is not a common consequence of chronic nutrient depletion.

A. Moisture from bowel and bladder incontinence B. High sensory perception in the lower body C. Paralysis with limited mobility D. Poor nutritional intake E. Strong ability to reposition independently F. Decreased sensation

Correct Answer is ["A","C","D","F"]

Explanation

A. Moisture from bowel and bladder incontinence: Constant moisture from incontinence leads to maceration of the skin, weakening its integrity and making it more prone to breakdown. Damp linens overnight further increase exposure.

B. High sensory perception in the lower body: Marcus has decreased sensation in the buttocks and lower extremities, not high sensory perception. High sensory perception would actually protect against injury because he could feel discomfort and reposition.

C. Paralysis with limited mobility: Paralysis prevents Marcus from repositioning independently, leading to prolonged pressure over bony prominences (e.g., sacrum). Immobility is one of the strongest predictors of pressure injury.

D. Poor nutritional intake: He consumes only 30–40% of meals, has low albumin, and recent weight loss. Poor nutrition impairs wound healing, reduces tissue tolerance, and increases susceptibility to pressure injury. |

E. Strong ability to reposition independently: Marcus cannot reposition independently due to paralysis. If he had strong ability, it would reduce risk.

F. Decreased sensation: Loss of sensation means Marcus cannot feel pain or discomfort from pressure, moisture, or friction, so he doesn’t initiate protective movements. This contributes to unrecognized tissue damage.

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The nurse is assessing the abdomen of a woman who is eight months pregnant. Which characteristic is the nurse likely to observe? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Which of the following is common when a patient's nutritional reserves are depleted? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

Correct Answer is ["A","C","D","F"]

Explanation

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