A nurse is preparing to auscultate fetal heart tones for a client who is pregnant. Using Leopold maneuvers, the nurse palpates a round, firm, movable part in the fundal portion of the uterus and a long, smooth surface on the mother's right side. In which of the following maternal quadrants should the nurse auscultate fetal heart tones?

Right upper quadrant

Left lower quadrant

Right lower quadrant

Left upper quadrant

Answer and Explanation

The Correct Answer is A

Choice A rationale: Auscultating fetal heart tones in the right upper quadrant is not appropriate based on the information provided by Leopold maneuvers, which indicates the fetal back is on the right side of the mother's abdomen, and the fetal head is in the fundal portion of the uterus.
Choice B rationale: During Leopold maneuvers, the nurse palpated a round, firm, movable part in the fundal portion of the uterus. This finding corresponds to the fetal head, which is typically located at the top of the uterus (fundus). Additionally, the nurse palpated a long, smooth surface on the mother's right side. This finding indicates the fetal back, which typically lies along the right side of the mother's abdomen, suggesting that the fetus's back is positioned anteriorly (toward the mother's front). The location of the fetal heart is typically best heard over the back of the fetus. Therefore, the nurse should auscultate the fetal heart tones in the maternal quadrant corresponding to the back of the fetus, which is the left lower quadrant.
Choice C rationale: The information from Leopold maneuvers does not indicate the fetal back is in the right lower quadrant. The nurse should not auscultate fetal heart tones in this area.
Choice D rationale: Auscultating fetal heart tones in the left upper quadrant is not appropriate based on the information provided by Leopold maneuvers, which indicates the fetal head is in the fundal portion of the uterus and the fetal back is on the right side of the mother's abdomen. The fetal heart is usually best heard over the back of the fetus, which is not in the left upper quadrant.

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Correct Answer is A

Explanation

Choice A rationale:

Newborns of diabetic mothers are at risk of developing hypoglycemia (low blood sugar) after birth, especially if they are large for gestational age like the newborn in this scenario.
Choice B rationale:

Hypercalcemia (high blood calcium levels) is not a typical concern in newborns of diabetic mothers, and it is not directly related to the baby's size.
Choice C rationale:

Decreased REC (Respiratory Exchange Capacity) is not a common issue in this scenario, and it is not related to the baby's size or the mother's diabetes.

A. Dry the infant off and cover the head. B. Stimulate the infant to cry. C. Clear the respiratory tract. D. Clamp the umbilical cord.

Correct Answer is A

Explanation

Choice A rationale: Drying the newborn and covering the head are essential steps in the immediate care of a newborn after birth. This helps prevent heat loss and promotes thermal stability for the baby.
Choice B rationale: Stimulating the newborn to cry is not the first priority in the immediate post-birth care. Drying and keeping the baby warm are more critical at this stage.
Choice C rationale: Clearing the respiratory tract may be necessary if there are signs of respiratory distress, but it is not the first action in the routine care of a newborn immediately after delivery.
Choice D rationale: Clamping the umbilical cord is usually done after the immediate care of the newborn is addressed, and it is not the first step in the initial care following a vaginal delivery.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a newborn who weighs 5,160 g (11 lb, 6 oz) and whose mother has diabetes mellitus. For which of the following data should the nurse monitor?

Correct Answer is A

Explanation

A nurse is assisting with the care of a newborn following a vaginal delivery. Which of the following actions should the nurse perform first?

Correct Answer is A

Explanation

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