The nurse who is assessing a G2 P1 client palpates the fundal height at the location noted on the picture below (near the umbilicus). The nurse concludes that the fetus is equal to which of the following gestational ages?
16 weeks.
20 weeks.
24 weeks.
28 weeks.
The Correct Answer is B
Choice A rationale
At 16 weeks, the fundal height is typically below the umbilicus. This location is more indicative of a fetus at around 20 weeks.
Choice B rationale
At 20 weeks, the fundal height is usually at the level of the umbilicus, indicating this is the correct gestational age.
Choice C rationale
At 24 weeks, the fundal height is usually above the umbilicus, suggesting a more advanced gestation than the picture indicates.
Choice D rationale
At 28 weeks, the fundal height is significantly above the umbilicus, making this option incorrect for the given scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Hepatitis B immune globulin at 1 week followed by hepatitis B vaccine monthly for 6 months is incorrect. This schedule delays the immune response and leaves the infant unprotected during the critical early period when the risk of transmission is highest.
Choice B rationale
Hepatitis B immune globulin and hepatitis B vaccine within 12 hr of birth is the correct approach. This combination provides immediate passive immunity through the immune globulin and active immunity through the vaccine, significantly reducing the risk of hepatitis B transmission from mother to child.
Choice C rationale
Hepatitis B vaccine monthly until the newborn tests negative for the hepatitis B surface antigen is incorrect. Monthly administration alone is insufficient without the initial dose of immune globulin, especially since the infant may remain at risk until the negative test result.
Choice D rationale
Hepatitis B vaccine at 24 hr followed by hepatitis B immune globulin every 12 hr for 3 days is incorrect. The delay in the first vaccine dose reduces its efficacy, and the immune globulin schedule does not align with established guidelines for preventing hepatitis B transmission.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale: Administer IV fluids with electrolytes: This is crucial to rehydrate the client and correct electrolyte imbalances caused by excessive vomiting, a common complication of hyperemesis gravidarum.
Choice B rationale: Offer small, frequent meals high in protein: Small, frequent meals can help manage nausea and vomiting by preventing the stomach from becoming empty, while high-protein foods can provide necessary nutrients and energy.
Choice C rationale: Administer antiemetics as prescribed: Antiemetics can help control nausea and vomiting, improving the client's ability to tolerate oral intake and maintain hydration and nutrition.
Choice D rationale: Encourage the client to increase oral fluid intake immediately: While increasing oral fluid intake is beneficial, it may not be immediately feasible due to the severity of nausea and vomiting in hyperemesis gravidarum. Hence, initial IV fluid therapy is prioritized.
Choice E rationale: Perform continuous fetal monitoring: Continuous fetal monitoring is not typically necessary in the early stages of pregnancy, especially at 11 weeks of gestation. The primary focus should be on stabilizing the mother's condition to support overall pregnancy health.
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