The nurse is measuring the fundal height on a 28-week client who presents to the office with a history of no prenatal care.
Which statement made by the client indicates that the nurse has accurately educated them about the task being performed?
Measuring fundal height can be a highly invasive procedure.
Fundal height evaluates fetal growth in the second and third trimesters.
The fundal height is measured from the umbilicus to the fundus.
Fundal height is only done once during the initial antepartum assessment.
The Correct Answer is B
Assessing fetal well-being through fundal height measurement requires knowledge of gestational benchmarks and anatomical landmarks. The nurse must apply the McDonald technique, measuring from the symphysis pubis to the top of the uterus, to evaluate appropriate growth patterns during pregnancy.
Choice A rationale
Fundal height measurement is a non-invasive, external procedure using a tape measure. It involves palpating the abdomen to find the uterine fundus and does not require internal examination or high-risk maneuvers, making this statement clinically inaccurate and misleading.
Choice B rationale
Fundal height is a standard screening tool used from 20 weeks until term to evaluate fetal growth. Between 20 and 36 weeks, the measurement in centimeters generally correlates with the gestational age in weeks, within a range.
Choice C rationale
The correct measurement starts at the symphysis pubis and extends to the top of the fundus. Measuring from the umbilicus is incorrect, as the umbilicus is only a landmark for approximately 20 weeks of gestation, not the base.
Choice D rationale
Fundal height is performed at every prenatal visit after 20 weeks to monitor consistent growth trends. A single measurement provides a baseline but cannot track the serial progression necessary to identify intrauterine growth restriction or macrosomia over time..
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
Triage in a clinic setting requires prioritizing clients based on the potential for permanent harm or transmission. Knowledge of infectious disease impacts on fetal development and the urgency of preventing congenital complications is vital for determining the order of care.
Choice A rationale
Syphilis during pregnancy poses an immediate threat to the fetus, including risks of stillbirth, neonatal death, or congenital syphilis. Early treatment with penicillin is critical to prevent vertical transmission and ensure the health of the developing fetus.
Choice B rationale
A painful penile lesion is often a symptom of herpes or chancroid, which requires evaluation and treatment but is not immediately life-threatening. While uncomfortable, this client is stable and does not take priority over the risk to a fetus.
Choice C rationale
Herpes simplex virus is a chronic condition that causes painful outbreaks but is generally managed with antiviral medications in an outpatient setting. It does not present the same level of urgency as an active syphilis infection in pregnancy.
Choice D rationale
Requesting education for the HPV vaccine is a preventive health measure and is classified as non-urgent. This client is stable and can wait until higher-priority cases involving active infections and pregnancy risks have been addressed by the provider..
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.