A nurse is preparing to palpate the uterine fundus of a client who is at 22 weeks of gestation to measure fundal height. At which of the following locations should the nurse expect to find the fundus?
3 cm below the umbilicus
5 cm above the umbilicus
3 cm above the umbilicus
At the umbilicus
The Correct Answer is D
At 22 weeks of gestation, the uterine fundus is typically located at or near the level of the umbilicus. Fundal height generally corresponds to gestational age in centimeters, so at 22 weeks, the fundus is expected to be approximately 22 cm from the pubic symphysis, which aligns with the umbilicus.
- A. 3 cm below the umbilicus: This is too low, as the fundus at 22 weeks should be at or slightly above the umbilicus.
- B. 5 cm above the umbilicus: This is too high, as the fundus typically reaches this level closer to 24–26 weeks.
- C. 3 cm above the umbilicus: This is slightly higher than expected for 22 weeks, though the fundus may be just above the umbilicus in some cases.
- D. At the umbilicus: This is the most accurate, as the fundus is typically at the level of the umbilicus at 20–22 weeks.
Final Answer: D. At the umbilicus
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
No explanation
Correct Answer is B
Explanation
A.Monitoring vital signs during the admission of a client with gestational hypertension requires nursing judgment and assessment skills.
B. Providing a sitz bath to a client with a fourth-degree laceration and is 2 days post- partum can be delegated to an AP. This task does not require the nurse's clinical judgment or assessment skills, and it can be safely performed by the AP following the nurse's instructions.
C.Observing an area of redness on the breast requires nursing assessment and intervention.
D.Changing the perineal pad of a client who has just been transferred from the labor ward is a task that should not be delegated to an assistive personnel (AP) since it is beyond their scope.This task requires assessment skills to evaluate the amount and type of lochia (postpartum vaginal discharge) and to monitor for signs of complications such as hemorrhage or infection. These assessments are within the scope of practice for a registered nurse.
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