A nurse is assessing fetal heart tones for a client who is pregnant. The nurse has determined the fetal position as left occipital anterior. To which of the following areas of the client's abdomen should the nurse apply the ultrasound transducer to assess the point of maximum Intensity of the fetal heart?
Left upper quadrant
Right upper quadrant
Left lower quadrant
Right lower quadrant
The Correct Answer is C
Choice A Reason:
Left upper quadrant is incorrect. The left upper quadrant is less likely to be the area where the point of maximum intensity of the fetal heart is heard when the fetal position is left occipital anterior.
Choice B Reason:
Right upper quadrant is incorrect. The right upper quadrant is not the typical location for assessing fetal heart tones when the fetal position is left occipital anterior. The heart tones are generally heard more towards the left side.
Choice C Reason:
Left lower quadrant is correct. Placing the ultrasound transducer in the left lower quadrant is likely to provide the best detection of the fetal heart tones in the described fetal position.
Choice D Reason:
Right lower quadrant is incorrect. Similar to the right upper quadrant, the right lower quadrant is not the optimal location for assessing the fetal heart when the fetal position is left occipital anterior. The left side is typically where the point of maximum intensity is found.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B, C, D, A
Explanation
Correct Answer is A
Explanation
The correct answer is A. Blood pressure 80/56 mm Hg.
A. A blood pressure of 80/56 mm Hg is the priority finding. Opioid analgesia can cause hypotension, and addressing low blood pressure is crucial to prevent maternal and fetal complications. The nurse should notify the healthcare provider promptly and implement interventions to improve blood pressure.
B. Profuse itching is a common side effect of opioids and is generally not considered a priority unless it becomes severe or is accompanied by other concerning symptoms.
C. A temperature of 38.2°C (100.8°F) may indicate a fever, but addressing hypotension takes precedence. Elevated temperature can be further assessed but is not the priority in this scenario.
D. The client reporting weakness of the lower extremities is a concerning symptom, but the priority is to address hypotension first, as it could be related to opioid-induced hypotension.
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