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 D

Explanation

Choice A Reason:

Hct 39.6 is incorrect. This hemoglobin level is within a typical range and may not require immediate intervention.

Choice B Reason:

Serum albumin 4.5 g/dL is incorrect. A serum albumin level of 4.5 g/dL is within the normal range and does not suggest an urgent issue.

Choice C Reason:

WBC 9,000/mm³ is incorrect. A white blood cell count of 9,000/mm³ is within the normal range and is not typically a cause for immediate concern in the absence of other symptoms or indications.

Choice D Reason:

Platelets 50,000/mm³ is correct. A platelet count of 50,000/mm³ is significantly below the normal range and may indicate thrombocytopenia, a condition associated with preeclampsi

A. Thrombocytopenia in preeclampsia can lead to bleeding complications and requires close monitoring and management.

A. Provide clean, dry underpads. B. Monitor the client's temperature. C. Assess the fetal heart rate. D. Assess the odor of the amnio?s fluid

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.

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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 reviewing the medical record of a client who is postpartum and has preeclampsi

Correct Answer is D

Explanation

A nurse is caring for a client who is in labor and assists the provider who performs an amniotomy. Which of the following is the priority action by the nurse following the procedure?

Correct Answer is C

Explanation

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