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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A sore throat, often due to Streptococcus pyogenes, is a significant precursor to acute rheumatic fever. The body’s immune response to the infection can attack its own tissues, leading to rheumatic heart disease if untreated.
Choice B rationale
Influenza is a viral infection and does not typically lead to acute rheumatic fever. While it can cause significant illness, its mechanism and sequelae are unrelated to those of rheumatic fever.
Choice C rationale
Chickenpox, caused by the varicella-zoster virus, presents with distinct symptoms like a vesicular rash and is not linked to rheumatic fever. It primarily affects the skin and nervous system, not the heart.
Choice D rationale
Mumps, a viral infection, mainly impacts the salivary glands and sometimes the pancreas and testes but is not associated with rheumatic fever. Its pathology differs from the immune-mediated damage seen in rheumatic fever.
Correct Answer is B
Explanation
Choice A rationale
While routine follow-up is necessary, these findings suggest magnesium sulfate toxicity, requiring immediate attention beyond routine monitoring. Hence, this is not the correct action.
Choice B rationale
Although reporting abnormal findings to the healthcare provider is critical, not all findings are necessarily outside acceptable ranges. This choice lacks the specificity needed in this context, making it less appropriate.
Choice C rationale
Increasing primary IV fluids could help with low urine output but would not address potential magnesium toxicity, which is the primary concern indicated by the assessment. Therefore, it is not the correct conclusion.
Choice D rationale
The findings suggest magnesium toxicity, including decreased respirations, reduced urine output, and deep tendon reflexes. Close follow-up, including immediate medical intervention, is needed to manage this potential toxicity.
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