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A nurse is caring for a client in the obstetric clinic who is 22 weeks of gestation, calculated by her last menstrual period.The fundal height measurement is 19 centimeters.This measurement could indicate which of the following? (Select all that apply).

A.

Intrauterine growth restriction.

B.

Consistent for estimated gestational age by LMP.

C.

Fetal anomaly.

D.

Polyhydramnios.

E.

Miscalculation of due date.

Question Solution

Correct Answer : A,C,E

Choice A rationale

 

Intrauterine growth restriction (IUGR) can result in a smaller fundal height measurement than expected for gestational age. This condition indicates that the fetus is not growing at the normal rate inside the womb.

 

Choice B rationale

 

A fundal height measurement of 19 centimeters at 22 weeks of gestation is not consistent with the estimated gestational age by LMP. Typically, the fundal height in centimeters should be approximately equal to the number of weeks of gestation.

 

Choice C rationale

 

Fetal anomalies can affect the size and growth of the fetus, leading to discrepancies in fundal height measurements. This could result in a smaller or larger than expected measurement.

 

Choice D rationale

 

Polyhydramnios, or excessive amniotic fluid, would typically result in a larger fundal height measurement than expected for gestational age. Therefore, this choice is incorrect.

 

Choice E rationale

 

Miscalculation of the due date can lead to discrepancies in fundal height measurements. If the gestational age is miscalculated, the fundal height may not match the expected measurement for the given weeks of gestation.


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Correct Answer is C

Explanation

Choice A rationale

Allowing the older sibling to hear the baby’s heartbeat at a prenatal visit can help them feel involved and connected to the new baby. This can be a positive experience and does not require follow-up by the nurse.

Choice B rationale

Enrolling the older sibling in a sibling preparation class at the hospital is a good way to prepare them for the arrival of the new baby. These classes often provide valuable information and help older siblings understand what to expect.

Choice C rationale

Bringing the new baby home as a surprise can be problematic. It may cause the older sibling to feel excluded or unprepared for the new addition to the family. It is important to involve the older sibling in the process and prepare them for the changes that will come with the new baby.

Choice D rationale

Allowing the older sibling to pick out a gift for the baby and having a gift for them from the baby can help foster a positive relationship between the siblings. This approach can make the older sibling feel valued and included.

Correct Answer is C

Explanation

Choice A rationale

Providing additional information about the disorder is appropriate as it helps the couple understand the condition better and prepare for the future. This information can include the nature of the disorder, potential complications, and available treatments or interventions.

Choice B rationale

Referring the couple to a disorder-specific support group is also appropriate. Support groups can provide emotional support, practical advice, and a sense of community for families facing similar challenges. This can help the couple cope with the diagnosis and connect with others who have similar experiences.

Choice C rationale

Determining whether termination has been considered is inappropriate because the couple has already decided to continue the pregnancy. Bringing up termination at this point can be distressing and may undermine their decision. The nurse should respect their choice and focus on providing support and information relevant to continuing the pregnancy.

Choice D rationale

Explaining that they may experience grief, which is normal, is appropriate. Grief is a common response to learning about a serious genetic disorder in a fetus, and normalizing these feelings can help the couple process their emotions and seek appropriate support.

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