# A nurse is assessing a pregnant client at 24 weeks gestation during a routine prenatal visit and measures a fundal height of 20 cm. Which action should the nurse take first? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=542828 > language: ko > subject: Maternal Newborn Health ## 문제 A nurse is assessing a pregnant client at 24 weeks gestation during a routine prenatal visit and measures a fundal height of 20 cm. Which action should the nurse take first? ## 보기 1. 20 cm 2. 24 cm **✔ 정답** 3. 28 cm 4. 32 cm **정답: 2** ## 해설 At 24 weeks gestation, expected fundal height is approximately 24 cm (±2 cm), correlating with gestational age. Other options indicate potential growth issues. ## 심화 해설 Understanding the Question and the Expected Fundal Height The nurse is assessing a pregnant client at 24 weeks gestation and measures a fundal height of 20 cm. The question asks for the correct action, and the provided answer choices are different fundal height measurements. The correct answer is 24 cm. This indicates the question is testing the knowledge that between approximately 20 and 36 weeks of gestation, the fundal height in centimeters should correlate closely with the gestational age in weeks. For a client at 24 weeks, the expected fundal height is 24 cm. The measured height of 20 cm is a significant discrepancy, suggesting a potential complication such as intrauterine growth restriction (IUGR), oligohydramnios, or inaccurate dating. The nurse's first action upon identifying this discrepancy is to recognize that the expected measurement should be 24 cm, which prompts further assessment and reporting. Connecting Fundal Height Discrepancy to Clinical Decision Support The critical role of accurate assessment and adherence to clinical guidelines in this scenario is strongly supported by the research on digital health interventions. A cluster-randomised controlled trial demonstrated that implementing a digital health registry with clinical decision support significantly improved the quality of antenatal care [3]. In the study, clinics using the eRegistry, which provides point-of-care prompts based on guidelines, showed better health worker compliance with screening and management protocols compared to those using paper records [3]. For a nurse, this underscores the principle that identifying an abnormal finding, like a fundal height that is not equal to the gestational age, must trigger a guideline-based response. The "first action" is the cognitive step of recognizing the expected norm (24 cm) against which the actual finding (20 cm) is compared, a process that digital tools are designed to reinforce to prevent oversight [3]. The Broader Context of Antenatal Screening and Risk Prediction A fundal height measurement that lags behind the expected value can be an early indicator of a fetus that is not growing appropriately. This assessment is part of a broader screening process to identify risks for adverse outcomes. For instance, a study on predicting large-for-gestational-age (LGA) newborns highlights how multiple antenatal factors, including gestational weight gain and maternal characteristics, are integrated to assess fetal growth trajectories . While that specific study focuses on excessive growth, the principle is identical: a single-point measurement like fundal height is a screening tool that, when abnormal, necessitates a more detailed evaluation. A measurement of 20 cm at 24 weeks is a red flag that requires the nurse to consider other risk factors and prepare for further diagnostic steps, such as an ultrasound, to investigate the cause of the size-date discrepancy . Why Other Interventions Are Not the First Action The provided evidence from other studies clarifies why actions beyond recognizing the discrepancy are not the immediate first step. A trial on preventing spinal anesthesia-induced hypotension in cesarean deliveries focuses on a highly specific, protocol-driven intervention using fluid responsiveness and vasopressors . This is an acute, intrapartum management strategy, not a response to a screening finding in a routine prenatal visit. Similarly, a study on interdental brushing to reduce obstetrical complications investigates a preventive strategy targeting a modifiable risk factor (gingivitis) over the course of pregnancy . While crucial for overall health, initiating oral hygiene counseling is not the priority response to an acute finding of a lagging fundal height. The nurse's immediate cognitive action is to identify the normal parameter (24 cm), recognize the deviation, and then follow the clinical pathway for further investigation, which may include reviewing the gestational dating, assessing for risk factors, and notifying the provider.References (research sources) - [3]A digital health registry with clinical decision support for improving quality of antenatal care in Palestine (eRegQual): a pragmatic, cluster-randomised, controlled, superiority trial.RCT/clinical trialVenkateswaran M, Ghanem B, Abbas E, Khader KA, Ward IA, Awwad T, Baniode M, Frost MJ, Hijaz T, Isbeih M, Mørkrid K, Rose CJ, Frøen JF. (2022) · DOI: 10.1016/s2589-7500(21)00269-7 ## 임상 시나리오 A nurse performs a routine prenatal assessment on a client at 24 weeks gestation and obtains a fundal height measurement of 20 cm. The nurse recognizes that the expected fundal height should be approximately 24 cm, based on the clinical guideline that fundal height in centimeters correlates with gestational age in weeks between 20 and 36 weeks. This 4 cm discrepancy is a significant finding that requires immediate clinical reasoning and action. Clinical Decision Guide - **Verify the Measurement:** Re-measure the fundal height to ensure the initial finding was accurate and not due to improper technique, maternal bladder distention, or fetal positioning. - **Review Dating and History:** Confirm the gestational age by reviewing the date of the last menstrual period (LMP) and any first-trimester ultrasound reports. Assess for risk factors such as hypertension, smoking, or poor weight gain. - **Assess for Other Signs:** Evaluate for signs of oligohydramnios (e.g., easily palpable fetal parts) or IUGR. Check fetal heart rate and inquire about fetal movement. - **Report and Escalate:** Promptly notify the healthcare provider of the size-dates discrepancy. The provider may order diagnostic tests such as an obstetric ultrasound to evaluate fetal growth, amniotic fluid volume, and placental function. - **Patient Education and Support:** Explain the reason for concern and the plan for further evaluation to the client in a clear, supportive manner, while avoiding causing undue alarm. Utilizing digital health registries with integrated clinical decision support at the point of care has been shown to improve adherence to such screening guidelines, prompting health workers to act on identified discrepancies. ## 핵심 개념 - **Fundal Height** — The distance from the pubic symphysis to the top of the uterine fundus, measured in centimeters; from 20-36 weeks gestation, it should correlate closely with gestational age in weeks. - **Intrauterine Growth Restriction (IUGR)** — A condition where the fetus is smaller than expected for the gestational age, often suspected when fundal height is significantly less than expected. - **Oligohydramnios** — A condition of having too little amniotic fluid, which can be a cause of a fundal height measurement smaller than expected for the gestational age. ## 같은 주제 문제 - [A nurse is assessing the fundal height of a pregnant client at 28 weeks gestation during a…](https://mymerci.kr/pages/nclex_q.php?qn_id=542826) - [A nurse is assessing the fundal height of a pregnant client at 28 weeks gestation during a…](https://mymerci.kr/pages/nclex_q.php?qn_id=542827) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._