A nurse is caring for a client who is pregnant and is at the end of her first trimester. The nurse should place the Doppler ultrasound stethoscope in which of the following locations to begin assessing for the fetal heart tones (FHT)?
Just above the umbilicus
Just above the symphysis pubis
The right lower quadrant
The left lower quadrant
The Correct Answer is B
The correct answer is B. Just above the symphysis pubis.
A. Just above the umbilicus: At the end of the first trimester, the uterus is still within the pelvic cavity, and fetal heart tones are typically not detectable above the umbilicus at this stage.
B. Just above the symphysis pubis: This is the correct placement for assessing fetal heart tones during the first trimester. The fetal heart is usually located low in the pelvis during early pregnancy, making it most easily heard just above the pubic bone.
C. The right lower quadrant: Fetal heart tones are typically assessed in the midline of the abdomen, and focusing on the lower quadrants may not be the optimal location, especially in the first trimester.
D. The left lower quadrant: Similar to the right lower quadrant, focusing on the lower quadrants may not be the most appropriate location for assessing fetal heart tones during the first trimester.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is B. Place the client in the lateral position.
A. Increasing the rate of maintenance IV infusion may be necessary, but the initial action should be to address potential aortocaval compression. Repositioning the client to the lateral position helps alleviate compression on the vena cava and improves blood flow to the uterus.
B. Placing the client in the lateral position is the correct first action. Changing the client's position, particularly from a supine to a side-lying position, can relieve aortocaval compression and improve uteroplacental perfusion.
C. Elevating the client's legs is not the priority in this situation. Repositioning the client to the lateral position is more important to address potential aortocaval compression.
D. Administering oxygen using a nonrebreather mask may be indicated, but repositioning the client to the lateral position is the first action to address potential aortocaval compression. Oxygen administration can follow if necessary.
Correct Answer is B
Explanation
The correct answer is B. Turn the client onto her side.
A. Administering oxygen to the client is a reasonable intervention in the presence of late decelerations, but turning the client onto her side is the priority action to relieve potential compression of the vena cava and improve fetal oxygenation.
B. Turning the client onto her side is the correct first action.
Late decelerations are often associated with uteroplacental insufficiency. Changing the client's position, especially to the left lateral position, can help alleviate pressure on the vena cava, improving blood flow to the uterus and fetal oxygenation.
C. Increasing the client's IV fluid infusion rate may be considered, but it is not the first action to address late decelerations. Positioning changes should be initiated promptly.
D. Palpating the client's uterus is an assessment that may be done, but it is not the first action when late decelerations are observed. Positioning changes take precedence.
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