A nurse is auscultating fetal heart tones with a Doppler device for a client who is at 12 weeks of gestation. Where should the nurse expect to auscultate the fetal heart tones?
Umbilical area
Suprapubic area
Above the left iliac crest
Below the liver border on the right abdomen
The Correct Answer is C
Rationale:
A) Incorrect - The umbilical area is not a typical location for auscultating fetal heart tones.
B) Incorrect - The suprapubic area is not a common location for auscultating fetal heart tones.
C) Correct - At 12 weeks of gestation, the nurse would typically auscultate the fetal heart tones above the left iliac crest, which is in the lower abdomen. This is where the uterus is located at this stage of pregnancy.
D) Incorrect - Auscultating below the liver border on the right abdomen is not a standard practice for fetal heart tone assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","F","H"]
Explanation
A) Glucose level might need to be assessed if there are signs of hypoglycemia or other concerns.
B) Mucous membrane assessment: Dry mucous membranes might indicate dehydration or other issues that need further evaluation.
C. Respiratory rate: The respiratory rate is not provided in the assessment, so there's no basis to report it. The assessment did not mention any abnormal respiratory rate.
D) The sclera color indicates that the newborn has jaundice, which is a common condition in newborns but requires monitoring and treatment to prevent complications.
E. Intake and output: Intake and output are not mentioned in the assessment, so there's no basis to report it. This information is not provided in the assessment findings.
F) The Coombs test result is important for assessing the presence of antibodies that could lead to hemolytic disease of the newborn due to blood type incompatibility with the mother, which can also cause jaundice and other serious problems.
G. Heart rate: The heart rate is not mentioned in the assessment, so there's no basis to report it. The assessment did not mention any abnormal heart rate.
H) Head assessment findings, such as soft and flat fontanels along with a molded head, should be communicated for further evaluation. The head assessment finding of caput succedaneum is a swelling of the scalp caused by pressure during delivery, which usually resolves within a few days but can increase the risk of jaundice and infection.
Correct Answer is A
Explanation
A) Correct - Encouraging the client to void often is important, as a full bladder can increase discomfort and interfere with labor progress.
B) Incorrect- Remaining awake between contractions might not directly address pain management strategies.
C) Incorrect- Position changes can help with pain management, so minimizing them would not be appropriate.
D) Incorrect- The presence of a support person is often encouraged during labor, and there is no need to limit their time in the room.
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