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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Rust-stained urine: This is a common finding in newborns and is due to urate crystals in the urine. It is benign and typically resolves as the infant's kidney function matures.
B. Transient circumoral cyanosis: This is a common finding in newborns, particularly during crying or feeding, and it usually resolves on its own. It does not typically indicate a serious condition.
C. A single palmar crease (also known as a simian crease) can be a normal variant, but it is often associated with certain congenital anomalies or chromosomal disorders, such as Down syndrome. The nurse should report this finding to the provider for further evaluation and possible genetic testing.
D. Subconjunctival hemorrhage: This can occur during delivery due to the pressure of vaginal birth. It is harmless and usually resolves within a few weeks without treatment.
Correct Answer is B,D,C,A
Explanation
The correct answer is choice B, D, C, A. B. Compress the bulb syringe: The nurse should first compress the bulb syringe to expel air from it. This ensures that when it is placed in the newborn’s mouth or nose, it can create suction to effectively remove mucus. D. Place the bulb syringe in the newborn's mouth: The nurse should then place the compressed bulb syringe into the newborn’s mouth first, as clearing the mouth is essential before the nose to prevent aspiration. C. Use the bulb syringe to suction the newborn's nose: After suctioning the mouth, the nurse should use the bulb syringe to suction the nose. Suctioning the nose after the mouth helps to clear the airway more effectively and reduce the risk of mucus being aspirated into the lungs. A. Assess the newborn for reflex bradycardia: After suctioning, the nurse should assess the newborn for any signs of reflex bradycardia, which can occur due to vagal stimulation during suctioning. This ensures the newborn's heart rate and overall well-being are monitored.
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