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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: RhoGAM is not given solely based on blood loss. It is administered to prevent Rh isoimmunization, which is unrelated to the amount of blood loss.
Choice B rationale: If the client has previously given birth to an Rh-negative infant, she is already sensitized and would not require RhoGAM for this current ectopic pregnancy.
Choice C rationale: Rho(D) Immune globulin (RhoGAM) is given to Rh-negative individuals to prevent the development of Rh isoimmunization, which could occur if the client is exposed to Rh-positive blood. In the case of an ectopic pregnancy, there may be a possibility of fetal blood mixing with the mother's bloodstream, which could lead to sensitization in an Rh-negative individual.
Choice D rationale: The desire to conceive again does not dictate the need for RhoGAM. It is solely based on the client's Rh factor status and the potential for sensitization during the ectopic pregnancy.
Correct Answer is ["A","B","D","E"]
Explanation
Choice A rationale:
This statement indicates an understanding that a loose-fitting diaper will help prevent irritation and promote healing after circumcision.
Choice B rationale:
Applying petroleum jelly to the circumcision site helps keep the area moist and prevents the Plastibell from sticking to the penis during healing.
Choice C rationale:
While keeping the penis clean is essential, the use of soap is usually not recommended for the first few days after circumcision. Warm water and gentle patting are generally sufficient.
Choice D rationale:
Bleeding after circumcision should be reported to the doctor as it may indicate a complication that needs attention.
Choice E rationale:
The Plastibell device typically falls off on its own within a week after the circumcision procedure.
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