A nurse is assessing the fundal height of a pregnant client at 28 weeks gestation during a routine prenatal visit. Which finding would be considered normal for this gestational age?
1Fundal height of 24 cm
2Fundal height of 32 cm
3Fundal height of 28 cm✓ 정답
4Fundal height of 20 cm
해설
At 28 weeks, fundal height in cm should approximate gestational age in weeks, with a normal range of ±2-3 cm. A measurement of 28 cm is expected, indicating appropriate fetal growth.
Core Nursing ExplanationKey Concept Analysis: This question assesses the nurse's knowledge of Fundal height measurement, a key component of Antepartum assessment. The fundal height is the distance from the top of the pubic symphysis to the top of the uterus (fundus). It is a non-invasive, clinical tool used to estimate Gestational age and screen for potential issues like Intrauterine growth restriction (IUGR) or Polyhydramnios. The core principle is that, from approximately 20 to 34 weeks of gestation, the measurement in centimeters often corresponds closely to the gestational age in weeks.
Answer Rationale: Key Point! The general rule is: Fundal height (cm) ≈ Gestational age (weeks). For a client at 28 weeks gestation, a measurement of 28 cm is the expected norm. A normal variation of ±2-3 cm is typically acceptable (e.g., 25-31 cm at 28 weeks). Therefore, a fundal height of 28 cm is the correct finding.
Distractor Analysis:
Watch out for confusion! A fundal height of 24 cm (Option 1) or 20 cm (Option 4) at 28 weeks is significantly less than expected. This finding would raise concern for Small for gestational age (SGA), possible IUGR, inaccurate dating, or oligohydramnios, requiring further investigation.
Watch out for confusion! A fundal height of 32 cm (Option 2) at 28 weeks is significantly greater than expected. This finding could indicate Large for gestational age (LGA) fetus, multiple gestation (twins/triplets), polyhydramnios, uterine fibroids, or inaccurate dating.
Related Concepts: This assessment is part of the Leopold's maneuvers sequence. It's crucial to perform the measurement correctly: with an empty bladder, using a non-stretchable tape measure. Deviations from the expected measurement trigger further diagnostic steps, such as a Ultrasound for more accurate fetal biometry and amniotic fluid assessment.
Concept Summary
Concept
Description
Fundal Height
Distance from pubic symphysis to top of uterus. Used to estimate fetal growth and gestational age from 20-34 weeks.
Normal Rule
Fundal height (cm) ≈ Gestational age (weeks) ± 2-3 cm.
Significance of Low Measurement
Possible IUGR, SGA, oligohydramnios, fetal malposition, or inaccurate dating.
Significance of High Measurement
Possible LGA, multiple gestation, polyhydramnios, uterine fibroids, or inaccurate dating.
Nursing Action for Deviation
Report finding, prepare client for possible ultrasound, provide reassurance, and document accurately.
Side-by-Side Comparison!
Assessment Finding
Possible Indication
Typical Follow-up
Fundal height < Gestational age (e.g., 24 cm at 28 wks)
Ultrasound to confirm, screen for gestational diabetes (for macrosomia), monitor for preterm labor signs
Anatomy, Physiology & Pharmacology Points
Anatomy: The Fundus is the top, rounded portion of the uterus. It rises out of the pelvis at around 12 weeks gestation and reaches the xiphoid process by 36 weeks.
Physiology: The linear relationship between fundal height and gestational age is due to the predictable growth of the fetus, placenta, and amniotic fluid volume during the second and early third trimesters.
Pathophysiology: Deviations occur when one of the components of uterine contents (fetal size, amniotic fluid, placental size) is abnormal.
Memory Tips
Mnemonic: "Centimeters for Clocking weeks" or "The number of weeks should meet the number of centimeters."
Visual Cue: Imagine a ruler alongside the pregnant abdomen. At 28 weeks, the tape measure should read close to 28.
Association: Think of it as a quick "growth chart" for the pregnancy. Just like a child's height is plotted, the fundal height is plotted against gestational age.
High-Frequency NCLEX Topics
Fundal height assessment is a Core skill for maternity nursing. The NCLEX-RN frequently tests:
Identifying the normal expected measurement at a given gestational age.
Recognizing the nursing implications of an abnormal finding (e.g., "Which finding requires immediate follow-up?").
Knowing the correct procedure for measurement (empty bladder, position of client).
Watch Out for Question Variations!
The same concept can be tested in different ways:
Priority Action: "The nurse measures a fundal height of 24 cm at 28 weeks. What is the priority nursing action?" (Answer: Report the finding to the provider/initiate further evaluation).
Procedure: "Which client instruction is essential before measuring fundal height?" (Answer: Empty your bladder).
Interpretation: "A fundal height of 32 cm at 28 weeks is noted. The nurse should anticipate an order for which diagnostic test?" (Answer: Ultrasound).
Nursing Clinical Practice GuideClinical Scenario: You are a nurse in a prenatal clinic. Maria, a 28-year-old G2P1 at 28 weeks gestation, is here for her routine visit. She reports feeling fetal movements and has no complaints. Your role includes performing the initial physical assessment, including fundal height measurement.
Nursing Intervention Strategy:
Assessment:
Ensure Maria has emptied her bladder within the last 30 minutes for an accurate measurement.
Position her supine with a pillow under her head and knees (semi-Fowler's or slight knee flexion) to prevent supine hypotension.
Locate the Symphysis pubis and the top of the uterine fundus by palpation.
Use a non-stretchable paper tape measure. Place the zero end at the top of the symphysis pubis, stretch the tape smoothly over the contour of the abdomen to the top of the fundus. Document the measurement in centimeters.
Nursing Care & Communication:
If the measurement is within the expected range (e.g., 28 cm ± 3 cm), provide positive reinforcement: "Your measurement is right on track for 28 weeks, which is a great sign of baby's growth."
If the measurement is outside the expected range, do not alarm the client. Use neutral, factual language: "Today your measurement is a bit different than we typically see. This is a screening tool, and your provider may want to get a more detailed picture with an ultrasound to check on the baby. Let me go discuss this with them."
Patient Safety and Precautions:
Supine Hypotension Prevention: Never leave a pregnant client flat on her back for an extended period. Use lateral tilt or a pillow under one hip.
Infection Control: Perform hand hygiene before and after the procedure.
Accuracy: An overdistended bladder can falsely elevate the fundal height measurement by several centimeters.
Documentation: Precisely document the measurement (e.g., "FH: 28 cm") and the gestational age. Note any relevant factors (e.g., maternal obesity, which can make palpation and measurement less accurate).
Nursing Procedure & Medication FlowFundal Height Measurement Steps:
1. Prepare: Explain the procedure, ensure privacy, have client void.
2. Position: Assist client to a supine position with knees slightly bent.
3. Palpate: Using the ulnar side of your hand, gently palpate the abdomen to locate the fundus (top of the uterus) and the symphysis pubis (bony prominence above the pubic hairline).
4. Measure: Place the "0" mark of the tape at the top of the symphysis pubis. Hold the tape securely and extend it over the abdominal curve to the top of the fundus. Ensure the tape is snug but not tight.
5. Record: Note the centimeter measurement at the fundus.
6. Assist & Educate: Help the client sit up slowly, discuss the finding, and document.
A Word from Your Senior Nurse
"Fundal height is one of our oldest and simplest tools, but it's a powerful one. It connects your hands-on assessment directly to the well-being of the baby inside. In clinical practice, trust your measurement but also trust your global assessment. A mom who is measuring 'small' but has a history of small babies and has a active, healthy fetus on Doppler might be perfectly normal. Conversely, a mom measuring 'large' with new-onset edema and hypertension needs urgent attention. On the NCLEX, they test the textbook rule. In real life, you use that rule as a starting point for your critical thinking. Always ask: Does this finding fit the whole picture of this patient?"
Fundal Height — The distance from the top of the pubic symphysis to the top of the uterus (fundus), measured in centimeters. Used to estimate gestational age and fetal growth from 20-34 weeks.
Gestational Age — The duration of a pregnancy calculated from the first day of the last menstrual period (LMP), typically expressed in weeks.
Intrauterine Growth Restriction — A condition where a fetus is unable to achieve its genetically determined potential size, often resulting in a fundal height less than expected for gestational age.
Polyhydramnios — An excessive accumulation of amniotic fluid (>2000 mL or AFI >24 cm), often causing a fundal height greater than expected for gestational age.
Leopold's Maneuvers — A systematic method of abdominal palpation to determine fetal position, presentation, lie, attitude, and engagement. Fundal height measurement is often considered part of this assessment sequence.