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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A. "It sounds like you are feeling sad that things didn't go as planned."
A. This response reflects empathy and acknowledges the client's feelings without judgment. It validates the client's emotions and provides an opportunity for her to express her feelings further.
B. "Maybe next time you can have a vaginal delivery" is not an appropriate response as it assumes that the client will or should have another pregnancy and may have a vaginal delivery. It is more important to address the current emotions and experience.
C. "At least you know you have a healthy baby" dismisses the client's feelings of disappointment. While the health of the baby is important, it's essential to acknowledge and validate the client's emotional experience.
D. "You can resume sexual relations sooner than if you had delivered vaginally" is not relevant to the client's expressed disappointment about the mode of delivery. It may not be an appropriate or comforting statement given the context.
Correct Answer is A
Explanation
The correct answer is A. Blood pressure 80/56 mm Hg.
A. A blood pressure of 80/56 mm Hg is the priority finding. Opioid analgesia can cause hypotension, and addressing low blood pressure is crucial to prevent maternal and fetal complications. The nurse should notify the healthcare provider promptly and implement interventions to improve blood pressure.
B. Profuse itching is a common side effect of opioids and is generally not considered a priority unless it becomes severe or is accompanied by other concerning symptoms.
C. A temperature of 38.2°C (100.8°F) may indicate a fever, but addressing hypotension takes precedence. Elevated temperature can be further assessed but is not the priority in this scenario.
D. The client reporting weakness of the lower extremities is a concerning symptom, but the priority is to address hypotension first, as it could be related to opioid-induced hypotension.
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