The nurse is caring for a client of 22 weeks gestation who presents to the clinic for a follow-up prenatal visit.
Which of the following assessments should the nurse perform?
Fundal height.
Vaginal exam.
Leopold's maneuver.
Pregnancy history.
The Correct Answer is A
Prenatal assessment at 22 weeks focuses on monitoring fetal growth and maternal well-being. Nurses must apply knowledge of gestational milestones and anatomical landmarks. Assessing the fundus provides a non-invasive way to confirm that fetal development is progressing appropriately.
Choice A rationale
Fundal height measurement begins around 20 weeks. At 22 weeks, the fundus is typically located slightly above the umbilicus. This measurement in centimeters should correlate with the weeks of gestation to screen for appropriate fetal growth.
Choice B rationale
Routine vaginal exams are not indicated at 22 weeks unless the patient reports symptoms of preterm labor, leaking fluid, or bleeding. Unnecessary exams increase the risk of infection and are not part of a standard visit.
Choice C rationale
Leopold's maneuvers are used to determine fetal lie, presentation, and position. These are typically performed in the third trimester, around 36 weeks, when the fetus is large enough to palpate clearly through the abdomen.
Choice D rationale
Pregnancy history, including gravidity and parity, is collected during the initial prenatal intake visit. While updated at each visit for new symptoms, it is not a specific physical assessment tool like measuring the fundal height.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E","F"]
Explanation
The scenario requires an understanding of obstetric assessment and monitoring. Knowledge of prenatal diagnostics, physical assessment techniques for neurological and gestational health, and laboratory screening for infection or metabolic changes is necessary to identify appropriate nursing interventions within a comprehensive care plan.
Choice A rationale
Glucose tolerance tests screen for gestational diabetes mellitus by measuring blood glucose response to sugar loads. Normal fasting glucose is < 95 mg/dL. This monitors metabolic status and prevents maternal or neonatal complications during the pregnancy.
Choice B rationale
Assessing deep tendon reflexes evaluates neuromuscular irritability. It is crucial for clients at risk of preeclampsia or those receiving magnesium sulfate. Normal reflexes are 2+. Abnormal findings can indicate impending seizures or magnesium toxicity.
Choice C rationale
The non-stress test monitors fetal heart rate patterns in response to fetal movement. A reactive test shows two or more accelerations in twenty minutes. This non-invasive procedure assesses fetal well being and placental oxygenation.
Choice D rationale
A complete blood count monitors hemoglobin and hematocrit levels to detect anemia. Normal hemoglobin in pregnancy is > 11 g/dL. It also assesses white blood cell counts for infection and platelets for clotting disorders.
Choice E rationale
Vaginal examinations determine cervical dilation, effacement, and fetal station during labor. This assessment helps the nurse track labor progression. It is also used to evaluate for the rupture of membranes or presence of vaginal bleeding.
Choice F rationale
Urine dipsticks screen for proteinuria, glycosuria, and ketones. Proteinuria ≥ 1+ can indicate preeclampsia. Glucose in the urine may suggest diabetes. This bedside test provides immediate data regarding the client's renal and metabolic status.
Correct Answer is D
Explanation
This scenario requires understanding Rh incompatibility and passive immunity provided by RhoGAM. Nurses must apply knowledge of maternal antibody production prevention and the timing of prophylactic administration based on neonatal Rh status to ensure the safety of subsequent pregnancies for Rh negative mothers.
Choice A rationale
RhoGAM provides temporary passive immunity, lasting roughly 12 weeks. However, stating it only works for this duration oversimplifies the postpartum requirement. Postpartum administration depends specifically on the neonate being Rh positive to prevent maternal sensitization.
Choice B rationale
One dose is insufficient for total protection during and after pregnancy. Sensitization can occur during delivery when fetal and maternal blood mix. Subsequent doses are necessary after potential exposure events to ensure continued suppression of antibody formation.
Choice C rationale
Amniocentesis is an invasive procedure carries risks and is not used solely for routine blood typing. Neonatal blood type is safely determined using umbilical cord blood after birth, guiding the necessity of the 72 hour postpartum RhoGAM injection.
Choice D rationale
If the neonate is Rh positive, the mother needs a second dose within 72 hours of birth. This prevents the mother from developing permanent antibodies against Rh positive cells, which could jeopardize future pregnancies with Rh positive fetuses.
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