The nurse is preparing to measure the fundal height of a client at 16 gestational weeks. The nurse should prepare the client for this assessment by instructing the client to
The nurse is preparing to measure the fundal height of a client at 16 gestational weeks. The nurse should prepare the client for this assessment by instructing the client to
A. lay in a side-lying position with the knees bent.
[6%]
B. prepare for the insertion of an intravenous (IV) catheter.
[0%]
C. not to eat or drink two hours after this assessment.
[1%]
D. empty their bladder.
[92%]
Statistics
Subject/Lesson
Subject
Maternal & Newborn Health
Lesson
Antepartum
Client Need
Test Plan
Health Promotion and Maintenance
Related Topic
Ante/Intra/Postpartum and Newborn Care
Item Type
Item Type
Application
Explanation
Choice D is correct. Measuring the fundal height is a painless and noninvasive way to evaluate fetal growth patterns and confirm gestational age. The client should empty their bladder. A full bladder can interfere with an accurate fundal height measurement as it may push the uterus upward, providing a false elevation of the fundus.
Choice A is incorrect. The client should be in a supine position, and the nurse should palpate and measure the distance from the symphysis pubis to the top of the uterine fundus.
Choice B is incorrect. This is unrelated to fundal height measurement. IV catheter insertion is a different procedure not associated with this.
Choice C is incorrect. It is not necessary for the client to refrain from eating or drinking for any specific time after this measurement.
Additional Info
✓ To measure the fundal height, the client should empty their bladder and lay supine with her knees slightly flexed
✓ The nurse should take a tape measure and measure the height from the top of the symphysis pubis, over the abdominal curve, to the top of the fundus
✓ At 16 gestational weeks, the fundus can be found approximately halfway between the symphysis pubis and the umbilicus
✓ At 20-22 gestational weeks, the fundus can be found at the umbilicus
✓ At 36 weeks, the fundus is at the xiphoid process
