At 20-weeks gestation, a client who has gained 20 pounds (9.1 kg) during this pregnancy tells the nurse that she is feeling fetal movement.
Fundal height measurement is 20 cm, and the client’s only complaint is that her breasts are leaking clear fluid. Which assessment finding warrants further evaluation?

Leakage from breasts.

Gestational weight gain.

Presence of fetal movement.

Fundal height measurement.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Leakage of clear fluid from the breasts towards the end of the second trimester into the third trimester is normal. This fluid is colostrum, a precursor to breastmilk, and its presence indicates breast development in preparation for lactation.

Choice B rationale

An average weight gain during pregnancy is 25 to 35 pounds. In the second trimester, a woman should be gaining about 1 pound per week. A weight gain of 20 pounds by 20 weeks indicates the client is on track or has even gained slightly more than expected. However, further evaluation is important as excessive weight gain in pregnancy might be indicative of underlying conditions such as preeclampsia or gestational diabetes.

Choice C rationale

Fetal movement, also known as quickening, is a normal and expected occurrence around 18-20 weeks' gestation. It is a positive sign of fetal development and well-being.

Choice D rationale

Fundal height is the measure from the pubic symphysis to the top of the uterus. It is an indicator of fetal growth. A fundal height of 20cm at 20 weeks gestation suggests the pregnancy is progressing normally and the baby is growing appropriately.

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Correct Answer is B

Explanation

Choice A rationale

Cervical dilation is a sign of labor, but a dilation of 1 cm alone does not confirm active labor. It could be the early phase of labor or false labor.

Choice B rationale

Contractions that decrease with walking are typically associated with false labor. In true labor, contractions usually get stronger regardless of activity level.

Choice C rationale

While 2+ pitting edema in the lower extremities can be seen in pregnancy, it is not a reliable indicator of labor. It could be due to fluid retention or other conditions.

Choice D rationale

The status of the membranes (intact or ruptured) does not necessarily indicate whether a woman is in labor. Some women may experience membrane rupture before labor begins.

A. Assess deep tendon reflexes (DTRs) every 4 hours. B. Ensure calcium gluconate is immediately available. C. Insert a Foley catheter with a urimeter to monitor hourly output. D. Provide a quiet environment with subdued lighting.

Correct Answer is B

Explanation

Choice B rationale

When preparing to administer magnesium sulfate to a laboring client with elevated blood pressure, ensuring that calcium gluconate is immediately available is of the highest priority. Calcium gluconate is the antidote for magnesium sulfate toxicity, and having it readily available is crucial in case of an overdose.

Choice A rationale

While assessing deep tendon reflexes (DTRs) every 4 hours is an important part of monitoring a client receiving magnesium sulfate, it is not the most immediate priority when preparing to administer the medication.

Choice C rationale

Inserting a Foley catheter with a urimeter to monitor hourly output is an important part of the overall management of a client receiving magnesium sulfate. However, it is not the most immediate priority when preparing to administer the medication.

Choice D rationale

Providing a quiet environment with subdued lighting can contribute to the comfort of a laboring client. However, it is not the most immediate priority when preparing to administer magnesium sulfate.

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse is preparing to administer magnesium sulfate to a laboring client whose blood pressure has risen from 110/60 mmHg to 140/90 mmHg.Which nursing protocol is of the highest priority?

Correct Answer is B

Explanation

A patient in early labor is receiving oxytocin and begins to experience tachysystolic or tetanic contractions with variable fetal heart decelerations.What should the nurse do next?

Which type of anesthesia, when used with a laboring client, results in a loss of sensation confined to the vagina and perineum?

The healthcare provider prescribes magnesium sulfate 4 grams intravenously (IV) to be infused over 20 minutes for a client with preeclampsia. The IV bag contains magnesium sulfate 20 grams in dextrose 5% in water 500 mL. How many mL/hour should the nurse program the infusion pump?

The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations.What priority issue should the nurse address to ensure the newborn’s survival?

A neonate, who is one day old, develops a cephalhematoma.Which common complication should the nurse assess this neonate for?

The nurse observes on the fetal monitor that a laboring client has a variable deceleration. What action should the nurse implement first?

A father watching the admission of his newborn to the nursery notices that eye ointment is placed in the infant’s eyes. He asks the nurse what is the purpose of the ointment.The nurse would be correct in stating that the purpose for using the ointment is to:

During the newborn admission assessment, the nurse palpates the newborn’s scrotum and does not feel the testicles. Which assessment technique should the nurse perform next to verify the absence of testes?