A nurse is assessing a client who is at 39 weeks of gestation and determines that the fetus is in a left occipitoanterior position. On which of the following sites should the nurse place the external fetal monitor to hear the point of maximum impulse of the fetal heart rate?

Right upper quadrant

left upper quadrant

left lower quadrant.

right lower quadrant.

Answer and Explanation

The Correct Answer is C

A. This would be appropriate if the fetus were in a breech presentation.

B. This is incorrect because the fetal back is in the lower left quadrant, not the upper quadrant.

C. In the Left Occipitoanterior (LOA) Position, the fetal occiput (back of the head) is facing the mother’s left side and anteriorly (toward the front of the uterus). The fetal back will be on the left side of the maternal abdomen, making the PMI in the left lower quadrant. The best location to place the fetal monitor is over the fetal back, closest to the head. Since the fetus is cephalic (head down) in LOA position, the heart sounds are heard in the left lower quadrant.

D. This would be appropriate if the fetus were in a right occipitoanterior (ROA) position, but in LOA, the back is on the left.

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Correct Answer is A

Explanation

The nurse should inform the client that it is common for yellow discharge to form at the circumcision site during the first 24 to 72 hours following the procedure. This is due to the accumulation of exudate, which is a normal part of the healing process. The nurse does not need to obtain a sample of the discharge for laboratory testing. The povidone-iodine solution should not be applied to the circumcision site, as it can be caustic and delay healing. Wiping the discharge away gently with a washcloth and warm water may irritate the wound and cause additional trauma.

A. "This test will determine the amount of amniotic fluid around the fetus." B. "This test studies blood flow in the fetus and placenta using ultrasound waves." C. "This test will detect the presence of Rh-positive antibodies in your blood." D. "This test determines if your baby is at risk for developing hypoglycemia after birth."

Correct Answer is C

Explanation

: "This test will detect the presence of Rh-positive antibodies in your blood." The indirect Coombs' test is a blood test that is used to detect the presence of antibodies against red blood cells in a person's blood. It is commonly used to determine whether a pregnant woman is at risk of hemolytic disease of the newborn (HDN), a condition in which the mother's antibodies attack the red blood cells of the fetus.

Choice A is incorrect because the amount of amniotic fluid around the fetus is measured by an amniocentesis, not a Coombs' test. Choice B is incorrect because ultrasound studies blood flow in the fetus and placenta using sound waves, not ultrasound waves. Choice D is incorrect because hypoglycemia after birth is not related to the Coombs' test, but may be related to other tests, such as a blood glucose test.

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A nurse is assessing a client who is at 39 weeks of gestation and determines that the fetus is in a left occipitoanterior position. On which of the following sites should the nurse place the external fetal monitor to hear the point of maximum impulse of the fetal heart rate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who reports that her baby has yellow discharge forming at the circumcision site. Which of the following is an appropriate response by the nurse?

Correct Answer is A

Explanation

A nurse is providing teaching to a client about the purpose of her upcoming indirect Coombs' test. Which of the following statements should the nurse include in the teaching?

Correct Answer is C

Explanation

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