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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: Vitamin K deficiency in newborns can cause bleeding disorders due to impaired clotting, but it does not cause jaundice. Jaundice is related to bilirubin metabolism, not coagulation pathways.
Choice B rationale: Physiologic jaundice typically appears after 24 hours of life due to immature liver function. Jaundice observed immediately at birth suggests a pathologic cause, not physiologic immaturity.
Choice C rationale: Maternal cocaine abuse may cause neonatal irritability, tremors, or growth restriction, but it is not directly linked to jaundice. Cocaine affects neurobehavioral outcomes, not bilirubin metabolism.
Choice D rationale: Maternal/newborn blood group incompatibility (e.g., ABO or Rh) causes hemolysis of fetal red blood cells, leading to elevated bilirubin levels and jaundice within the first 24 hours—hallmark of pathologic jaundice.
Correct Answer is B
Explanation
Choice A reason:
Covering the cord with a sterile, moist saline dressing can help to maintain the cord's viability by preventing drying and possible infection. However, this action does not address the immediate concern of relieving pressure on the cord to restore fetal circulation.
Choice B reason:
Placing the client in the knee-chest position is the most immediate and critical action to take. This position helps to relieve pressure on the prolapsed cord, which is vital to prevent compression of the cord and maintain blood flow to the fetus. It is a recommended emergency intervention for umbilical cord prolapse.
Choice C reason:
Inserting a gloved hand into the vagina to relieve pressure on the cord is a measure that may be taken by a healthcare provider in the event of a cord prolapse. However, it is not the first action to be performed. The initial step is to change the mother's position to relieve pressure on the cord.
Choice D reason:
Preparing the client for an immediate birth is necessary because umbilical cord prolapse is an obstetric emergency that requires prompt delivery, often by cesarean section, to prevent fetal hypoxia. However, the very first action is to relieve pressure on the cord to restore fetal oxygenation while preparations for delivery are made.
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