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?
Right upper
Left upper
Left lower
Right lower
The Correct Answer is A
The correct answer is: d. Right lower
Choice A: Right upper
Reason: The right upper quadrant is not typically where fetal heart tones are auscultated when the fetal back is on the right side and the head is in the lower part of the uterus. This area is more likely to be associated with the breech presentation if the fetus’s head is in the fundus.
Choice B: Left upper
Reason: The left upper quadrant would be considered if the fetal back was on the left side and the head was in the fundus. Since the nurse palpated the fetal back on the right side, this option is not applicable.
Choice C: Left lower
Reason: The left lower quadrant would be relevant if the fetal back was on the left side and the head was in the lower part of the uterus. Given the fetal back is on the right side, this is not the correct location.
Choice D: Right lower
Reason: The correct answer is the right lower quadrant. When the nurse palpates a round, firm, movable part (likely the head) in the fundus and a long, smooth surface (the back) on the right side, it indicates that the fetus is in a cephalic (head-down) position with its back on the right. Therefore, the fetal heart tones are best auscultated in the right lower quadrant.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Increased deposits of fat in the chest and shoulder area are not typically associated with respiratory distress syndrome in a newborn. Macrosomic newborns, or those with a high birth weight, may have increased fat deposits, but this is not the primary cause of respiratory distress.
Choice B rationale
A brachial plexus injury is a type of birth injury that can occur due to difficulties during delivery, such as a prolonged labor or a breech presentation. It involves damage to the bundle of nerves that supply the arms and hands. However, it does not directly cause respiratory distress syndrome.
Choice C rationale
Increased blood viscosity could potentially contribute to respiratory distress, but it is not the most likely cause in a macrosomic newborn whose mother has poorly controlled type 2 diabetes. High blood sugar levels in the mother can lead to high insulin levels in the newborn, which is a more direct cause of respiratory distress.
Choice D rationale
Hyperinsulinemia, or high levels of insulin in the blood, is the most likely cause of respiratory distress in this case. When a mother has poorly controlled diabetes, the baby’s pancreas may respond to high glucose levels by producing extra insulin. After birth, the baby may have hypoglycemia (low blood sugar) and increased red blood cell production, both of which can contribute to respiratory distress.
Correct Answer is A
Explanation
Step 1 is to calculate the volume of Toradol to be drawn up. Toradol is available in 60 mg/mL. Therefore, to administer a dose of 30 mg, the nurse would need to draw up 30 mg ÷ 60 mg/mL = 0.5 mL.
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