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NurseDive Free Nursing Practice Question
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?
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. 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.
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Full Explanation
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
Similar Questions
A nurse is teaching a new mother about signs of effective breastfeeding of her newborn. Which of the following information should the nurse include in the teaching?
A. Your baby should gain 0.25 oz (7 grams) per day after the fourth day of life.
B. Expect your baby to have less than 5 wet diapers per day after the fourth day of life.
C. Your baby can lose 5% of body weight during the first 3 days of life.
This is a normal physiological process as the baby adjusts to feeding and eliminates excess fluids. However, the other options provided are not accurate indicators of effective breastfeeding. The expected weight gain of a breastfed baby is typically 0.5 to 1 ounce (15 to 30 grams) per day after the first few days. It is also expected for a breastfed baby to have at least 6 wet diapers per day after the fourth day of life, indicating adequate hydration. Lastly, while it is normal for newborns to feed frequently, it is not accurate to state that they will feed constantly for the entire first week of life.
D. Expect your baby to feed constantly the first week of life.
The dark, red uterine discharge expelled in the first 2-3 days postpartum is called:
A. lochia rubra
Lochia is the term used to describe the vaginal discharge that occurs after childbirth as the uterus sheds its lining. Lochia rubra is the initial stage of lochia, characterized by dark red blood mixed with mucus and tissue debris. It typically lasts for the first few days after delivery. After lochia rubra, the discharge transitions to a lighter color and consistency, known as lochia serosa, followed by lochia alba, which is a whitish or yellowish discharge.
B. lochia germosa
C. lochia serosa
D. lochia alba
A nurse is assisting with the care of a client who is receiving oxytocin via IV infusion following a vaginal delivery. Which of the following findings should the nurse monitor to evaluate effectiveness of this medication?
A. Blood pressure
B. Urinary output
C. Pulse rate
D. Fundal consistency
Oxytocin is commonly administered following a vaginal delivery to promote uterine contraction and prevent postpartum hemorrhage. One of the key indications of the medication's effectiveness is the firmness or consistency of the uterine fundus. The nurse should assess the fundus regularly to ensure it remains firm and well-contracted. If the fundus remains boggy or soft, it may indicate inadequate contraction and the need for further intervention.