A 34-week gestation multigravida comes to the clinic for her bimonthly appointment.
Which assessment finding should the nurse report to the healthcare provider (HCP)?

Weight gain of 2 pounds (0.91 kg).

1+ edema on her lower extremities.

Fundal height of 30 cm.

Fetal heart rate of 110 beats/minute.

Answer and Explanation

The Correct Answer is C

Choice A rationale

A weight gain of 2 pounds (0.91 kg) in a 34-week gestation multigravida is generally considered normal. During the third trimester, it is typical for a pregnant woman to gain around 0.5 to 1 pound per week. This weight gain helps support the growing fetus and prepare the mother's body for labor and breastfeeding. However, sudden or excessive weight gain could indicate fluid retention or preeclampsia, but a 2-pound gain alone is not necessarily a concern.

Choice B rationale

1+ edema on the lower extremities is a common finding during pregnancy, especially in the later stages. It is usually due to increased blood volume and pressure on the pelvic veins from the growing uterus, which can slow the return of blood from the legs. While some degree of edema is normal, particularly in the ankles and feet, it is important to monitor for sudden or severe swelling, which could be a sign of preeclampsia.

Choice C rationale

A fundal height of 30 cm at 34 weeks gestation is concerning because it is less than the expected measurement. Fundal height typically corresponds to gestational age in centimeters (±2 cm). Therefore, at 34 weeks, the expected fundal height would be between 32 and 36 cm. A smaller fundal height could indicate intrauterine growth restriction (IUGR), oligohydramnios, or other fetal development issues, which require further evaluation by the healthcare provider.

Choice D rationale

A fetal heart rate (FHR) of 110 beats per minute (bpm) is within the normal range for a fetus. The normal FHR typically ranges from 110 to 160 bpm. Although 110 bpm is on the lower end of the normal range, it is still considered acceptable. Significant deviations from the normal range, either too low (bradycardia) or too high (tachycardia), could indicate fetal distress and require immediate attention.

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Correct Answer is D

Explanation

Choice A rationale

Blow-by oxygen delivery can provide some additional oxygen to the apneic newborn, but it may not be effective in stimulating breathing or providing adequate ventilation. It is a less direct method of addressing apnea compared to positive pressure ventilation.

Choice B rationale

Starting an IV infusion in a scalp vein is important for medication administration or fluid resuscitation but is not the immediate priority for a newborn who is apneic and has a heart rate of 100 beats per minute. Establishing adequate ventilation takes precedence to ensure oxygenation and stabilize the newborn.

Choice C rationale

Assisting the neonatologist with intubation may be necessary if positive pressure ventilation is unsuccessful or if there are signs of severe respiratory distress. However, the immediate next step for an apneic newborn with a heart rate of 100 beats per minute should be to provide positive pressure ventilation to stimulate breathing.

Choice D rationale

Providing positive pressure ventilation is the recommended immediate action for a newborn who remains apneic and has a heart rate of less than 100 beats per minute. This intervention helps to inflate the lungs, establish effective breathing, and improve oxygenation, which is critical for the newborn's survival.

A. I'm glad your mother told you why you were coming to the hospital. B. Tell me what an operation is. C. We're going to do everything we can to take very good care of you. D. Are you scared.

Correct Answer is B

Explanation

Choice A rationale

Telling the child that you're glad the mother explained the procedure doesn't provide the child with an opportunity to express their understanding or concerns. It is important to engage the child directly to understand what they know and how they feel about the operation, rather than relying solely on what the parent has communicated.

Choice B rationale

Asking the child to explain what an operation is allows the nurse to gauge the child's understanding and provides an opportunity to correct any misconceptions. This approach also encourages open communication and helps the child feel more involved and informed about their own care, which can reduce anxiety.

Choice C rationale

Reassuring the child that the hospital staff will take very good care of them is comforting, but it doesn't address the child's need for information and understanding about the operation. While it's important to provide reassurance, the primary focus should be on ensuring the child comprehends what will happen.

Choice D rationale

Directly asking the child if they are scared might lead to a yes or no answer, and doesn't necessarily encourage them to share their specific fears or concerns. It is more effective to ask open-ended questions that allow the child to express their feelings in more detail, which can then be addressed by the nurse.

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A 34-week gestation multigravida comes to the clinic for her bimonthly appointment. Which assessment finding should the nurse report to the healthcare provider (HCP)?

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Naxlex Comprehensive Predictor Exams

Following a vaginal delivery, the nurse places the neonate under the radiant warmer to elicit spontaneous respirations. The newborn has a heart rate of 100 beats per minute and remains apneic when the nurse flicks the soles of the feet. Which action should the nurse implement next?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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A 34-week gestation multigravida comes to the clinic for her bimonthly appointment.
Which assessment finding should the nurse report to the healthcare provider (HCP)?