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

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A Reason:

"I should have a goal of maintaining my fasting blood glucose between 100 and 120." This statement does not indicate understanding of the teaching. Recommended target for fasting blood glucose levels during pregnancy in women with diabetes is typically lower, often between 60 and 90 mg/dL.

Choice B Reason:

"I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater." This statement does not indicate understanding of the teaching . Exercising when blood glucose is already elevated to 250 or greater may not be safe. Exercise is generally recommended to help manage blood glucose levels, but the specific approach and timing should be discussed with the healthcare provider.

Choice C Reason:

"I will continue taking my insulin if I experience nausea and vomiting." This statement reflects an awareness of the importance of continuing insulin administration even if the client is experiencing nausea and vomiting. Consistent insulin management is crucial for maintaining blood glucose levels within the target range during pregnancy.

Choice D Reason:

"I will ensure that my bedtime snack is high in refined sugar." This statement does not indicate understanding of the teaching. Bedtime snacks should focus on providing sustained energy and stabilizing blood glucose levels. A snack high in refined sugar is not recommended as it can lead to fluctuations in blood glucose levels.

A. Monitor the fetal heart rate (FHR) every hour B. Insert an indwelling urinary catheter. C. Keep four side rails up while the client is in bed D. Check the cervix prior to analgesic administration

Correct Answer is A

Explanation

The correct answer is A. Monitor the fetal heart rate (FHR) every hour.

A. Monitoring the fetal heart rate every hour is a crucial aspect of the plan of care during active labor. Continuous fetal monitoring helps assess the well-being of the baby and ensures timely identification of any signs of fetal distress.

B. Inserting an indwelling urinary catheter is not a routine intervention during active labor. The bladder can be monitored using other non-invasive methods, and catheterization is generally reserved for specific indications.

C. Keeping four side rails up while the client is in bed is not recommended. It may limit the client's mobility and is not a standard practice during labor. Ensuring the safety of the client and promoting mobility is important.

D. Checking the cervix prior to analgesic administration may be necessary, but it is not a general action for every client in active labor. The need for cervical checks should be individualized based on the client's progress, preferences, and clinical indications.

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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)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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