A nurse in a clinic is preparing to measure the fundal height of a client who is pregnant. Which of the following actions should the nurse take?

Lay the tape measure horizontally over the middle of the client's abdomen.

Place the client in a left-lateral position to obtain the measurement.

Measure from the upper border of the symphysis pubis to the upper border of the fundus

Ensure that the client has a full bladder before taking the measurement.

Answer and Explanation

The Correct Answer is C

A. The tape measure should be placed vertically, not horizontally, over the abdomen to measure fundal height accurately.
B. The client should be in a supine position, not left-lateral, during the measurement.
C. Fundal height is measured from the upper border of the symphysis pubis to the upper border of the uterine fundus.
D. A full bladder can distort the measurement, so the client should have an empty bladder before measuring fundal height.

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Correct Answer is B

Explanation

A. Pale blue hands and feet (acrocyanosis) are normal during the first 24 hours after birth.
B. Soft grunting noises can indicate respiratory distress and should be reported promptly.
C. Blood-tinged vaginal discharge (pseudomenstruation) is normal in newborn females due to maternal hormones.
D. A positive Babinski reflex is a normal neurologic finding in newborns.

A. Vitamin B12 level B. Fatigue C. Ferritin level D. Orthostatic hypotension

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A,B,C"},"C":{"answers":"B"},"D":{"answers":"A,B,C"}}

Explanation

Vitamin B12 level: A B12 level of 159 pg/mL is below normal and consistent with pernicious anemia. This condition is caused by a lack of intrinsic factor, impairing B12 absorption in the gut. The client’s vegan diet may further reduce B12 intake, worsening deficiency.
Fatigue: Fatigue results from decreased oxygen delivery to tissues due to low hemoglobin in all anemias. In sickle cell disease, abnormally shaped RBCs impair perfusion. Iron and B12 deficiencies impair RBC production, further contributing to fatigue.
Ferritin level: Ferritin reflects the body’s iron storage, and a level of 8 ng/mL is below the normal range. Low ferritin confirms iron depletion, a hallmark of iron deficiency anemia. This can result from dietary lack or chronic inflammation, like in rheumatoid arthritis.
Orthostatic hypotension: Orthostatic hypotension may occur with all anemias due to reduced circulating volume and poor oxygenation. Low hemoglobin and hematocrit lead to impaired vascular tone and autonomic response, causing dizziness or lightheadedness when standing.

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A nurse in a clinic is preparing to measure the fundal height of a client who is pregnant. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn 4 hours after their birth. Which of the following findings should the nurse report to the provider?

Correct Answer is B

Explanation

A nurse in a provider's office is caring for a client. Exhibits For each client's finding, click to specify if the assessment finding is consistent with sickle cell disease, iron deficiency anemia, and/or pernicious anemia. Each finding may support more than 1 disease process.

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A,B,C"},"C":{"answers":"B"},"D":{"answers":"A,B,C"}}

Explanation

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A nurse is caring for a newborn Exhibits Complete the sentence below using the list of options The newborn is at highest risk of developing dropdown as evidenced by the newborn’s Blank 2 dropdown

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