A nurse is caring for a client who is 39 weeks pregnant and in active labor.
The nurse detects the fetal heart tones above the client’s umbilicus at the midline.
Which of the following positions should the nurse suspect the fetus is in?
Cephalic.
Posterior.
Transverse.
Frank breech.
The Correct Answer is D
A. In a cephalic (head-down) presentation, fetal heart tones are typically heard below the umbilicus.
B. A posterior position refers to the fetal back facing the mother's back, but it does not affect the heart tone location significantly.
C. A transverse lie would place the fetal heart tones at the lateral sides of the abdomen, not above the umbilicus.
D. In a frank breech position (buttocks presenting first), fetal heart tones are usually heard above the umbilicus, as the fetal head is positioned in the upper uterus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
The term “effaced” refers to the thinning of the cervix, which is a process that occurs as labor approaches. However, the documentation “-1” does not indicate the degree of cervical effacement.
Choice B rationale
The term “presenting part is 1 cm below the ischial spines” would be documented as “+1” in a vaginal examination. This indicates that the presenting part of the fetus (usually the head) is 1 cm below the ischial spines, which are bony landmarks in the maternal pelvis.
Choice C rationale
The documentation “-1” in a vaginal examination refers to the position of the presenting part of the fetus in relation to the ischial spines of the maternal pelvis. A “-1” indicates that the presenting part is 1 cm above the ischial spines. This is a common finding during labor and does not indicate any abnormality.
Choice D rationale
The term “dilated” refers to the opening of the cervix. In the context of labor and delivery, the cervix dilates from 0 to 10 cm to allow for the passage of the baby. However, the documentation “-1” does not provide information about the degree of cervical dilation.
Correct Answer is C
Explanation
Step 1: The order is to administer Morphine 5mg IV once immediately. The available concentration is 2.5 mg/mL. To find out how many mL of morphine the nurse should prepare for administration, we need to divide the ordered dose by the available concentration.
Step 2: Calculation: 5 mg ÷ 2.5 mg/mL = 2 mL So, the nurse should prepare 2 mL of morphine for administration.
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