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 C

Explanation

A. Assessing for tachysystole is important, but intervention is needed immediately to improve fetal oxygenation.
B. Internal monitoring may provide more accurate data, but it does not address the immediate fetal distress.
C. The first action should be to reposition the client to a left lateral position to improve uteroplacental blood flow and oxygenation to the fetus.
D. Increasing IV fluids can help with placental perfusion, but positioning is faster and more immediately effective.

A. 1 will expect my baby's umbilical cord to fall off in a couple of weeks." B. 1 will give my baby a tub bath once daily C. "I will place my baby on their side to sleep." D. 1 will compress the bulb syringe after I place it in my baby's mouth.”

Correct Answer is A

Explanation

A. The umbilical cord typically dries and falls off within 1 to 2 weeks after birth, which is a normal expectation.
B. Newborns do not need daily tub baths; a sponge bath 2–3 times a week is usually sufficient until the cord falls off.
C. Babies should always be placed on their backs to sleep to reduce the risk of sudden infant death syndrome (SIDS), not on their sides.
D. The correct technique for using a bulb syringe is to compress it before inserting it into the baby’s mouth or nose, then release to suction out secretions.

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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?

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