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 D
Explanation
A. Brownish vaginal discharge may indicate the presence of old blood or mucus and is not necessarily a cause for concern in the absence of other signs or symptoms.
B. Contractions occurring every 4 to 5 minutes are within the normal frequency range during the first stage of labor.
C. Pink mucoid vaginal discharge, also known as the "bloody show," is a common occurrence in early labor and is not typically a cause for immediate concern.
D. Contractions lasting 100 seconds are excessively long and are a cause for concern.
Prolonged contractions can lead to decreased uterine blood flow, impacting fetal oxygenation. Such prolonged contractions should be assessed and addressed promptly.
Correct Answer is D
Explanation
A. Discuss contraceptive options with the client and her partner.Discussing contraceptive options typically occurs later in the postpartum period, often during follow-up visits. This is not a priority during the early taking-hold phase, when the mother is focused on learning to care for herself and her baby.
B. Repeat information to ensure client understanding.Repeating information and ensuring understanding is more critical during the taking-in phase, which occurs in the first 24 to 48 hours postpartum, when the mother is more passive, fatigued, and focused on her own recovery. In the taking-hold phase, the mother is typically more alert and eager to learn.
C. Listen to the client and her partner as they reflect upon the birth experience.Reflecting on the birth experience is more aligned with the taking-in phase, when the mother is focused on herself and may need emotional support in processing the experience.
D. Demonstrate to the client how to perform a newborn bath.In the taking-hold phase, the mother is ready to take responsibility for the care of her newborn and actively seeks guidance. Demonstrating how to bathe the newborn is an appropriate intervention, as it provides practical support and helps the mother gain confidence in newborn care.
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