A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. The nurse locates the fetal heart tones above the client's umbilicus at midline. The nurse should suspect that the fetus is in which of the following positions?
Frank breech
Cephalic
Posterior
Transverse
The Correct Answer is A
A. Frank breech position
A. In a frank breech presentation, the baby's buttocks are the presenting part. When the nurse locates fetal heart tones above the client's umbilicus at midline during active labor, it is indicative of a breech presentation, and the frank breech position is one possibility.
B. In a cephalic presentation, which is the most common and ideal position for childbirth, the fetal head is the presenting part, and the fetal heart tones would typically be heard below the umbilicus.
C. In a posterior position, the back of the baby's head is against the mother's spine. Fetal heart tones in this position would be typically heard below the umbilicus.
D. In a transverse lie, the baby is positioned horizontally across the uterus. Fetal heart tones may be heard laterally in this position, not necessarily above the umbilicus at midline.
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Related Questions
Correct Answer is B
Explanation
The correct answer is B. Massage the client's back.
A. Turning the client onto her left side may be a comfort measure, but it is not specifically associated with the gate control theory of pain. It may help improve blood flow and relieve pressure but does not directly engage the gate control mechanism.
B. Massage the client's back is consistent with the gate control theory of pain.
According to the gate control theory, non-painful input (such as massage) can close the "gate" to painful input, reducing the perception of pain. Massage stimulates large-diameter nerve fibers, which can inhibit the transmission of painful signals.
C. Encouraging the client to rest between contractions is a general comfort measure but is not directly related to the gate control theory of pain.
D. Administering prescribed analgesic medication is a pharmacological approach to pain management and is not specifically associated with the gate control theory. Medications can act on pain receptors but do not engage the gate control mechanism.
Correct Answer is D
Explanation
The correct answer is D. Fetal engagement
A. Fetal position, fetal lie, and fetal attitude are important aspects of the fetal presentation but are not specific considerations when performing an amniotomy.
B. Fetal lie is the relationship between the long axis of the fetus and the long axis of the mother. It is not directly relevant to the consideration of amniotomy.
C. Fetal attitude refers to the relationship of the fetal body parts to each other. It is not a specific consideration for amniotomy.
D. Fetal engagement is the correct consideration prior to amniotomy.
Fetal engagement refers to the descent of the fetal presenting part into the pelvis. Before performing an amniotomy, it is important to confirm that the fetal head is engaged in the pelvis, ensuring a lower risk of cord prolapse.
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