In assessing a primigravida woman at 15 weeks gestation by dates, the nurse palpates the fundus at the umbilicus. Based on this assessment finding, it is most important for the nurse to obtain information about the occurrence of which condition?

Urinary frequency.

Lightening.

Fetal movement.

Braxton-Hicks contractions.

Answer and Explanation

The Correct Answer is C

A. Urinary frequency: Urinary frequency is common during pregnancy due to increased pressure on the bladder from the growing uterus. However, it is not directly related to fundal height assessment.

B. Lightening: Lightening is the descent of the baby's head into the pelvis, which typically occurs in the third trimester, not at 15 weeks.

C. Fetal movement: Fetal Movement is an appropriate choice because it directly relates to determining the presence of a viable fetus. This information can assist in ruling out a complete molar pregnancy, where no fetal movement would be expected. It can guide the nurse to investigate further, potentially leading to more specific diagnostic procedures such as an ultrasound to confirm the underlying cause of the abnormal fundal height.

D. Braxton-Hicks contractions: Braxton-Hicks contractions can occur throughout pregnancy, but they are not a cause for concern at 15 weeks.

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Correct Answer is D

Explanation

A. Longitudinal pigmented bands and red-brown linear streaks of recent onset. This description is more indicative of longitudinal melanonychia, which presents as pigmented bands along the length of the nail plate. It's not typically associated with finger clubbing.

B. Thinned, depressed nails with lateral edges tilting up to form a concave profile and proximal subungual fungal infection. This description suggests koilonychia, also known as spoon nails, which are characterized by thin, depressed nails with lateral edges tilting up. The mention of a fungal infection points to a different condition. It doesn't align with finger clubbing.

C. Transverse furrows and nail plate white spots that move forward with nail growth. This description corresponds to Beau's lines and leukonychia, which are not associated with finger clubbing. Beau's lines are transverse furrows or depressions in the nail plate, while leukonychia manifests as white spots or lines.

D. A nail base angle greater than 180 degrees and nail plate loosened at the distal-lateral edge, progressing proximally. This description fits the characteristics of finger clubbing, where there's an increased nail base angle (greater than 180 degrees) and the nail plate is loosened at the distal-lateral edge, progressing proximally. This choice aligns with the assessment finding.

A. Question the client about the frequency of falls in recent months. B. Request to have the client lie as still as possible for the assessment. C. Assist the client with clarifying values about end-of-life care options. D. Ask the client how often episodes of sundowning are experienced.

Correct Answer is A

Explanation

A. Question the client about the frequency of falls in recent months: Falls are a common concern in older adults. Assessing the frequency of falls helps identify potential safety risks and mobility issues. It provides valuable information about the client’s functional status and balance.

B. Request to have the client lie as still as possible for the assessment: While assessing functional status, it is essential to observe the client’s mobility and ability to perform activities of daily living (ADLs). Having the client lie still would not provide relevant information about their functional abilities.

C. Assist the client with clarifying values about end-of-life care options: While discussing end-of-life care is important, it is not directly related to assessing functional status. This action is beyond the scope of a functional assessment.

D. Ask the client how often episodes of sundowning are experienced: Sundowning refers to increased confusion, agitation, or behavioural changes in older adults during the late afternoon or evening. While relevant to overall well-being, it is not specifically related to functional assessment.

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In assessing a primigravida woman at 15 weeks gestation by dates, the nurse palpates the fundus at the umbilicus. Based on this assessment finding, it is most important for the nurse to obtain information about the occurrence of which condition?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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