A nurse in a prenatal clinic is caring for a client. Using Leopold's 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

Right lower

Left upper

Answer and Explanation

The Correct Answer is B

Choice A reason:

The left lower quadrant is not typically where fetal heart tones are auscultated when the round, firm part of the fetus (usually the head) is palpated in the fundus and the long smooth surface (indicative of the back) is on the right side. Fetal heart tones are best heard through the back of the fetus, and in this position, the back is not located in the left lower quadrant.

Choice B reason:

The right upper quadrant is the correct location to auscultate fetal heart tones in this scenario. The Leopold's maneuvers suggest that the fetus is in a cephalic presentation with its back facing the right side of the mother's abdomen. Therefore, the fetal heart tones are most likely to be heard in the right upper quadrant, just below the level of the fundus.

Choice C reason:

The right lower quadrant is generally not the area to auscultate fetal heart tones if the fetus's back is on the right side and the head is in the fundus. The heart tones are typically higher up and closer to where the back is palpated.

Choice D reason:

The left upper quadrant would not be the correct place to find fetal heart tones given the described position of the fetus. With the back on the right side, auscultation on the left would not yield the clear heart tones expected.

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Correct Answer is D

Explanation

The correct answer is choice D: Document the findings and continue to monitor the client.

Rationale:

Choice A: While encouraging the client to empty her bladder is important to help with uterine contraction, it's not the priority in this situation. The client's fundus is firm and midline, indicating good uterine contraction.

Choice B: Increasing the frequency of fundal massage is not necessary when the fundus is firm and midline. Excessive fundal massage can lead to uterine fatigue and decreased contractility.

Choice C: Notifying the client's provider is not necessary for a moderate amount of lochia rubra and small clots in the early postpartum period. This is a normal finding.

Choice D: Documenting the findings and continuing to monitor the client is the correct action. The nurse should document the amount, color, and consistency of lochia, as well as the fundus assessment. The client should be monitored closely for any signs of excessive bleeding or uterine atony.

A. Iron is poorly absorbed in infants. B. Iron facilitates growth of bones in infants. C. Iron stores in infants begin to deplete. D. Iron facilitates development of vision in infants.

Correct Answer is C

Explanation

Choice A Reason:
Iron is not poorly absorbed in infants; in fact, infants absorb iron quite efficiently. Breast milk contains a small amount of iron, but it is highly bioavailable and well-absorbed. When switching to formula, it is important to use iron-fortified options to prevent iron deficiency anemia.

Choice B Reason:
While iron is essential for overall growth and development, including bone growth, it is not the primary reason for emphasizing iron in infant nutrition. The key concern with iron, especially when transitioning from breastfeeding, is the prevention of iron deficiency anemia, which can affect cognitive and motor development.

Choice C Reason:
This is the correct information to include in the teaching. Infants are born with a reserve of iron that begins to deplete around 4 to 6 months of age. It is crucial to introduce iron-fortified formula at this time to ensure the infant continues to receive adequate iron for development and to prevent iron deficiency anemia.

Choice D Reason:
Iron does play a role in the development of the nervous system, which can indirectly affect vision, but it is not specifically known for facilitating the development of vision in infants. The primary concern with iron intake in infants relates to its role in preventing anemia and supporting overall growth and development.

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A nurse in a prenatal clinic is caring for a client. Using Leopold's 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 1 hour postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the level of the umbilicus. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse in a clinic is teaching the mother of a 4-month-old infant who has been breastfed. The mother plans to switch her infant to an iron-fortified formula. Which of the following should be included in the teaching?

Correct Answer is C

Explanation

A nurse in a prenatal clinic is caring for a client who is pregnant and asks the nurse for her estimated date of birth (EDB). The client's last menstrual period began on July 27. What is the client's EDB? (State the date in MMDD format. For example, July 27 is 0727.)

A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa. The client asks the nurse why the provider does not perform an internal examination. Which of the following explanations of the primary reason should the nurse provide?

A nurse is caring for a client who has a suspected ectopic pregnancy at 8 weeks of gestation. Which of the following manifestations should the nurse expect to identify as consistent with the diagnosis?

A nurse in a family planning clinic is caring for a 17-year-old female client who is requesting oral contraceptives. The client states that she is nervous because she has never had a pelvic examination. Which of the following responses should the nurse make?

A nurse is caring for a client who has just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn?

A nurse is completing discharge teaching to a client in her 35th week of pregnancy who has mild preeclampsia. Which of the following information about nutrition should be included in the teaching?

A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity from magnesium sulfate therapy and report to the provider?

A nurse is providing teaching to a client who is pregnant and has phenylketonuria (PKU). Which of the following foods should the nurse instruct the client to eliminate from her diet?