The nurse is assessing a patient during a routine prenatal visit. ...

[Sportsfan2111]

The nurse is assessing a patient during a routine prenatal visit. Her pregnancy has been unremarkable, and at her last visit her fundal height measurement was 23 cm. The nurse measures the patient's fundal height at 24 cm. What is the next nursing action?
 
  a. Ask the patient when she last felt fetal movement.
  b. Palpate the patient's bladder to determine if it is full.
  c. Review the patient's chart for her pattern of weight gain.
  d. Assess the patient's deep tendon reflexes (DTRs) bilaterally at the patella.

Question 2

A pregnant client reports that she works in a long-term care setting and is concerned about the impending flu season. She asks about receiving the flu vaccine.
 
  As the nurse, you are aware that some immunizations are safe to administer during pregnancy, whereas others are not. Which vaccines could this client receive? (Select all that apply.)
 
  a. Tetanus
  b. Varicella
  c. Influenza
  d. Hepatitis A and B
  e. Measles, mumps, rubella (MMR)

[juliaf]

Answer to Question 1

ANS: A
Between 16 and 36 weeks, fundal height measurement corresponds with the weeks of gestation. The patient was last at the clinic at 23 weeks and would be rescheduled to return at 27 week, or in 4 weeks. The fundal height is 3 cm less than it should be, so the nurse is concerned about fetal well-being. Fetal movement is one of the first indicators of fetal well-being. If the patient's bladder is full, the fundal height measurement will surpass the expected finding. Weight gain can be an indicator of well-being, nutritional status, and excess fluid volume. It is not as reliable an indicator as fetal movement for well-being. DTRs are assessed routinely to assess for hyperreflexia associated with gestational or pregnancy-induced hypertension.

Answer to Question 2

ANS: A, C, D
Inactivated vaccines such as those for tetanus, hepatitis A, hepatitis B, and influenza are safe to administer to women who have a risk for contracting or developing the disease.
Immunizations with live virus vaccines such as MMR, varicella (chickenpox), or smallpox are contraindicated during pregnancy because of the possible teratogenic effects on the fetus.