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
The correct answer is Choice D
Choice A rationale: Notifying the provider is important but not the first priority in this situation. The maternal hypotension (BP 92/54 mm Hg) and elevated maternal heart rate (128/min) suggest decreased perfusion, which can compromise uteroplacental blood flow. Immediate intervention is required before notifying the provider, especially if positioning can restore circulation and fetal oxygenation. Waiting to call without correcting the underlying cause may result in fetal distress or worsening maternal status.
Choice B rationale: While uncontrolled pain may contribute to elevated maternal heart rate, the hypotension and tachycardia suggest a more urgent hemodynamic imbalance. Pain management may become appropriate after stabilizing maternal circulation. Focusing on pain relief first delays essential interventions to improve perfusion, risking fetal compromise due to inadequate uteroplacental oxygen delivery. The fetal heart rate of 130/min is reassuring, but maternal circulation must be prioritized to sustain it.
Choice C rationale: A full bladder can contribute to uterine displacement, but there is no indication in the scenario that bladder distention is an issue. Voiding may be done later but does not address the immediate concern of maternal hypotension and compensatory tachycardia. Uteroplacental perfusion depends heavily on maternal blood pressure, and bladder status has secondary importance in the acute phase of circulatory compromise.
Choice D rationale: Elevating one hip improves venous return and cardiac output by relieving pressure on the inferior vena cava, which is compressed by the gravid uterus in the supine position. This correction reduces hypotension and restores uteroplacental perfusion. The maneuver is a first-line response for maternal hypotension in labor, helping stabilize both mother and fetus quickly. Fetal oxygen delivery depends on adequate maternal perfusion, which this position supports.
Correct Answer is A
Explanation
Choice A rationale
Placing the client in a lateral position can help improve blood flow to the uterus and placenta, which can help stabilize the client’s blood pressure and the fetal heart rate.
Choice B rationale
Monitoring vital signs every 5 minutes is important, but the priority action is to address the client’s low blood pressure, which can compromise blood flow to the fetus.
Choice C rationale
Elevating the client’s legs can help increase venous return and improve blood pressure, but it is not the priority action in this situation.
Choice D rationale
Notifying the provider is important, but the nurse should first take action to stabilize the client’s condition.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.