Nokea
Which of the following fundal heights indicates less than 12 weeks' gestation when the date of the LMP is unknown?
- A. Uterus in the pelvis
- B. Uterus at the xiphoid
- C. Uterus in the abdomen
- D. Uterus at the umbilicus
Correct Answer: A
Rationale: When the LMP is unknown, the gestational age of the fetus is estimated by uterine size or position (fundal height). The presence of the uterus in the pelvis indicates less than 12 weeks' gestation. At approximately 12 to 14 weeks, the fundus is out of the pelvis above the symphysis pubis. The fundus is at the level of the umbilicus at approximately 20 weeks' gestation and reaches the xiphoid at term or 40 weeks.
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After 4 hours of active labor, the nurse notes that the contractions of a primigravida client are not strong enough to dilate the cervix. Which of the following would the nurse anticipate doing?
- A. Obtaining an order to begin IV oxytocin infusion
- B. Administering a light sedative to allow the patient to rest for several hour
- C. Preparing for a cesarean section for failure to progress
- D. Increasing the encouragement to the patient when pushing begins
Correct Answer: A
Rationale: The client's labor is not progressing due to inadequate contractions, so the nurse should anticipate obtaining an order for an IV oxytocin infusion to augment labor. Oxytocin increases the frequency and strength of contractions, aiding cervical dilation. Sedatives are used for hypertonic contractions, and a cesarean section is premature at this stage.
Which of the following factors would the nurse suspect as predisposing a client to placenta previa?
- A. Multiple gestation
- B. Uterine anomalies
- C. Abdominal trauma
- D. Renal or vascular disease
Correct Answer: A
Rationale: Multiple gestation is a predisposing factor for placenta previa, as it increases the likelihood of the placenta implanting low in the uterus. Uterine anomalies, abdominal trauma, and renal or vascular disease are not directly associated with placenta previa.
A client has a midpelvic contracture from a previous pelvic injury due to a motor vehicle accident as a teenager. The nurse is aware that this could prevent a fetus from passing through or around which structure during childbirth?
- A. Symphysis pubis
- B. Sacral promontory
- C. Ischial spines
- D. Pubic arch
Correct Answer: C
Rationale: A midpelvic contracture could prevent the fetus from passing through or around the ischial spines, which are located in the mid-pelvis and can be narrowed by previous injury. The symphysis pubis, sacral promontory, and pubic arch are not primarily affected in the mid-pelvis.
A client 12 weeks' pregnant comes to the emergency department with abdominal cramping and moderate vaginal bleeding. Speculum examination reveals 2 to 3 cm cervical dilation. The nurse would document these findings as which of the following?
- A. Threatened abortion
- B. Imminent abortion
- C. Complete abortion
- D. Missed abortion
Correct Answer: B
Rationale: Imminent abortion is documented when there is abdominal cramping, moderate vaginal bleeding, and cervical dilation (2-3 cm), indicating inevitable pregnancy loss. Threatened abortion involves bleeding without dilation, complete abortion involves full expulsion of products, and missed abortion involves fetal demise without expulsion.
A nurse is caring for a postpartum person during the fourth stage of labor. The nurse is assessing uterine involution to ensure that the uterus is returning to its prepregnancy size and position. Which finding is indicative of normal uterine involution during this stage?
- A. Uterus is palpable at the level of the umbilicus.
- B. Uterine fundus is firm, at the level of the umbilicus.
- C. Uterus is displaced to the right side of the abdomen.
- D. Uterine fundus is above the level of the umbilicus.
Correct Answer: B
Rationale: A firm uterine fundus at the level of the umbilicus is indicative of normal uterine involution during the fourth stage of labor.