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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Erb-Duchenne palsy involves injury to the upper brachial plexus, resulting in weakness or paralysis of the affected arm and an absent Moro reflex on that side.
B. Cleft palate is unrelated to Erb-Duchenne palsy.
C. The Babinski reflex is a neurological test of the lower limbs and is not affected by this condition.
D. Difficulty sucking and swallowing is not typical of Erb-Duchenne palsy but may be related to other cranial nerve injuries.

A. Inactivated influenza B. Human papillomavirus C. Measles, mumps, and rubella D. Varicella E. Diphtheria acellular pertussis

Correct Answer is ["A","E"]

Explanation

A. Inactivated influenza vaccine is safe and recommended during pregnancy to protect both mother and fetus.
B. Human papillomavirus (HPV) vaccine is not recommended during pregnancy.
C. Measles, mumps, and rubella (MMR) vaccine is a live vaccine and contraindicated during pregnancy.
D. Varicella vaccine is live and contraindicated during pregnancy.
E. The Tdap vaccine (diphtheria, acellular pertussis, tetanus) is recommended during each pregnancy, ideally between 27 and 36 weeks gestation to protect the newborn from pertussis.

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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

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