A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation.
At which location should the nurse expect to palpate the fundus?

1 cm below the umbilicus

3 cm below the umbilicus

2 cm above the umbilicus

3 cm above the umbilicus

Answer and Explanation

The Correct Answer is C

A. 1 cm below the umbilicus: This is too low for a client at 22 weeks of gestation.

B. 3 cm below the umbilicus: This is also too low for a client at 22 weeks of gestation.

C. 2 cm above the umbilicus: At 22 weeks of gestation, the fundus should be palpated about 2 cm above the umbilicus, which is at approximately the level of the maternal belly button.
D. 3 cm above the umbilicus: This is too high for a client at 22 weeks of gestation.

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Correct Answer is A

Explanation

A) Quickening: Quickening is the term used to describe the first perception of fetal movements by the pregnant woman. It typically occurs between 16 to 20 weeks of gestation, which aligns with the client's statement about feeling fluttering movements at 18 weeks.
B) Ballottement: Ballottement is a physical examination technique performed by a healthcare provider to assess the fetus's position in the uterus. It is not related to the client's perception of fetal movement.
C) Chloasma: Chloasma refers to hyperpigmented skin areas that can appear during pregnancy due to hormonal changes. It is not related to fetal movement.
D) Lightening: Lightening refers to the descent of the fetal head into the maternal pelvis, which typically occurs in the third trimester. It is not related to the feeling of fetal movements by the mother.

A. Engagement of the presenting part B. Progressive changes in the effacement and dilation of the cervix C. Rupture of the membranes D. Irregular pattern of contractions

Correct Answer is B

Explanation

Choice A: Engagement of the presenting part occurs when the baby's head descends into the pelvis. While it is a sign of labor progression, it can also happen weeks before labor begins.
Choice B: Progressive changes in the effacement (thinning) and dilation (opening) of the cervix are the most reliable signs of true labor. As the cervix changes, it indicates that labor is actively occurring.

Choice C: Rupture of the membranes (water breaking) is another sign of labor, but it can happen before or during labor. It may not be the most reliable sign by itself.
Choice D: Regular and frequent contractions are essential for labor to progress, but an irregular pattern of contractions may still be associated with false labor or early labor.

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A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 18 weeks of gestation. The client tells the nurse that she felt fluttering movements in her abdomen 3 days ago. The nurse should interpret this finding as which of the following?

Correct Answer is A

Explanation

A nurse is caring for a client who is a primigravida, at term, and having contractions. The client states that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as the most reliable sign of true labor?

Correct Answer is B

Explanation

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A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

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A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation.
At which location should the nurse expect to palpate the fundus?