— 健康促進與維護 · MEDIUM · SATA —
護理師為一位妊娠 28 週的孕婦進行評估，下列哪些發現是預期內的？（選所有適合的）
A nurse is conducting a health assessment for a client at 28 weeks gestation. Which findings should the nurse expect? (Select all that apply.)
- APresence of braxton hicks contractions✓ 正解出現布拉克斯頓·希克斯收縮
- BIncreased fetal activity✓ 正解胎動增加
- CDependent edema in the lower extremities✓ 正解下肢凹陷性水腫
- DBlood pressure elevated to 150/95 mmHg血壓升高至 150/95 mmHg
- EFundal height at approximately 28 cm✓ 正解宮底高度約為 28 cm
— Explanation · 中文詳解 —
懷孕 28 週時，宮底高度通常與週數一致（約 28 公分）。Braxton Hicks 收縮、下肢輕微水腫（因靜脈壓迫）及胎動增加皆為正常現象。血壓 150/95 mmHg 屬於高血壓範圍，必須排除子癇前症，不屬於正常預期發現。
At 28 weeks gestation, expected findings include painless irregular Braxton Hicks contractions, increased fetal activity in the third trimester, mild dependent lower-extremity edema from uterine pressure on venous return, and a fundal height in centimeters approximately equal to gestational age (20-34 weeks). A BP of 150/95 mmHg is hypertensive and warrants evaluation for preeclampsia/gestational hypertension—it is NOT an expected finding.
✦ 台美臨床差異
美國產檢注重護理師評估；台灣產檢多由婦產科醫師親自檢查，護理師衛教與測量比例較低。