A nurse assisting in the care of a client, places the tocodynamometer (TOCO) transducer on a client's fundus and secures it in place. The client asks the nurse to explain the purpose of the monitoring device. Which of the following responses should the nurse make?
"This monitor gives me information related to fetal heart rate fluctuations during your labor."
"This monitor measures the intensity and frequency of your contractions so I can observe labor progress."
"This monitor allows me to observe your labor progress. By observing the pattern, I can tell how strong your contractions are."
"This monitor provides me with information related to the duration and frequency of your contractions."
The Correct Answer is D
A. "This monitor gives me information related to fetal heart rate fluctuations during your labor." – Incorrect; the TOCO does not monitor fetal heart rate; the fetal heart rate is detected using a Doppler or fetal scalp electrode.
B. "This monitor measures the intensity and frequency of your contractions so I can observe labor progress." – Incorrect; the TOCO can measure frequency and duration, but not intensity (which requires an intrauterine pressure catheter).
C. "This monitor allows me to observe your labor progress. By observing the pattern, I can tell how strong your contractions are." – Incorrect; TOCO does not measure contraction strength, only duration and frequency.
D. "This monitor provides me with information related to the duration and frequency of your contractions." – Correct; a TOCO detects and records contraction frequency and duration, but not intensity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
A. Ask the client to empty their bladder – Correct; a full bladder can displace the uterus and prevent it from contracting effectively.
B. Perform fundal massage – Correct; fundal massage helps stimulate uterine contractions and reduce postpartum bleeding.
C. Nothing, this is an expected finding – Incorrect; a boggy uterus is not expected and requires intervention to prevent hemorrhage.
D. Ambulate the client in the hallway – Incorrect; while ambulation is beneficial postpartum, it is not the immediate intervention for a non-firm uterus.
E. Give pain medications – Incorrect; pain medications do not directly address uterine atony or bleeding.
Correct Answer is A
Explanation
A. Halfway between the symphysis pubis and the umbilicus. – Correct; at 16 weeks, the fundus is typically midway between the symphysis pubis and the umbilicus.
B. Just above the pubic bone – Incorrect; the fundus is at the pubic symphysis at 12 weeks, not 16 weeks.
C. The uterus would not be palpable at 16 weeks – Incorrect; the uterus is palpable by 12 weeks and grows above the symphysis pubis as pregnancy progresses.
D. At the umbilicus – Incorrect; the fundus reaches the umbilicus at 20 weeks, not 16 weeks.
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