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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is C. Assess the fetal heart rate.
A. Providing clean, dry underpads is important for maintaining cleanliness and comfort, but it is not the priority immediately following an amniotomy.
B. Monitoring the client's temperature is a consideration but is not the priority immediately following an amniotomy. Assessing the fetal well-being takes precedence.
C. Assessing the fetal heart rate is the priority action.
Following an amniotomy, there is a risk of cord prolapse or compression, and assessing the fetal heart rate helps detect any signs of fetal distress or compromise.
D. Assessing the odor of the amniotic fluid may be relevant, but it is not the immediate priority after an amniotomy. Focusing on fetal well-being is crucial.
Correct Answer is A
Explanation
Choice A Reason:
"You can miss your period for several other reasons. Describe your typical menstrual cycle." This response acknowledges that a missed period can result from various factors other than pregnancy, such as stress, changes in weight, hormonal fluctuations, or certain medical conditions. Understanding the client's typical menstrual cycle can help the nurse gather more information about potential reasons for the late period.
Choice B Reason:
"If you have been sexually active and haven't used protection, it is likely that you are pregnant. “This response assumes pregnancy without exploring other possibilities or the client's individual situation.
Choice C Reason:
"Let's check to see if you have any other signs of pregnancy. Have you noticed any abdominal enlargement yet?" While considering other signs of pregnancy is reasonable, focusing on abdominal enlargement may not be the most accurate early indicator, and it's essential to explore a broader range of symptoms.
Choice D Reason:
"Because you have missed your period, you should try taking a home pregnancy test before you start worrying. "While suggesting a home pregnancy test is reasonable, it may be more beneficial to gather additional information about the client's menstrual cycle and potential symptoms before jumping directly to a test.
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