A nurse in a prenatal clinic is caring for a client.
Using Leopold maneuvers, the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client’s right side.
In which abdominal quadrant should the nurse expect to auscultate fetal heart tones?
Left lower
Right upper
Left upper
Right lower
The Correct Answer is D
Choice A rationale
The left lower quadrant is not the most likely location to auscultate fetal heart tones if the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client’s right side. These findings suggest that the fetus is in a breech position with its back on the left side, which would place the fetal chest, and thus the heart tones, in the right lower quadrant.
Choice B rationale
The right upper quadrant is not the most likely location to auscultate fetal heart tones if the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client’s right side. These findings suggest that the fetus is in a breech position with its back on the left side, which would place the fetal chest, and thus the heart tones, in the right lower quadrant.
Choice C rationale
The left upper quadrant is not the most likely location to auscultate fetal heart tones if the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client’s right side. These findings suggest that the fetus is in a breech position with its back on the left side, which would place the fetal chest, and thus the heart tones, in the right lower quadrant.
Choice D rationale
The right lower quadrant is the most likely location to auscultate fetal heart tones if the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on
the client’s right side. These findings suggest that the fetus is in a breech position with its back on the left side, which would place the fetal chest, and thus the heart tones, in the right lower quadrant.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Hypomagnesemia is not typically a primary concern for newborns of mothers with diabetes mellitus. While it can occur in newborns, it is not directly related to macrosomia or maternal diabetes.
Choice B rationale
Hypocalcemia can occur in newborns, especially preterm infants, infants of diabetic mothers, and those with perinatal asphyxia. However, it is not the primary concern in this scenario.
Choice C rationale
Hyperbilirubinemia can occur in newborns for a variety of reasons, including prematurity, blood group incompatibility, and other factors. While infants of diabetic mothers may have an increased risk of jaundice, it is not the primary concern in this scenario.
Choice D rationale
Hypoglycemia is the correct answer. Infants of diabetic mothers are at risk for hypoglycemia after birth. During pregnancy, the fetus produces extra insulin in response to the mother’s high blood glucose levels. After birth, the newborn continues to produce extra insulin for a short time until it adjusts to normal glucose-insulin balance. This can lead to hypoglycemia, which is a primary concern and requires immediate attention.
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale
Allowing the newborn to continue crying is not recommended. Persistent crying can be a sign of discomfort or distress in the newborn, and it is important to identify and address the cause.
Choice B rationale
Swaddling the newborn in a receiving blanket can provide a sense of security and comfort, which can help soothe a crying newborn.
Choice C rationale
Carrying the newborn in a front or back pack can provide close physical contact and movement, both of which can be soothing to a crying newborn.
Choice D rationale
Keeping the newborn in the center of a large crib does not directly address the issue of persistent crying.
Choice E rationale
Taking the newborn for a ride in the car can provide soothing movement and noise, which can help calm a crying newborn.
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