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:
Maternal serum alpha-fetoprotein (MSAFP) determination is not used to screen for ABO incompatibility. It is specifically used to screen for certain fetal abnormalities.
Choice B rationale:
MSAFP determination is not used to screen for gestational diabetes. It is primarily used for detecting certain fetal abnormalities.
Choice C rationale:
The MSAFP test is a prenatal screening test that measures the level of alpha-fetoprotein in the mother's blood. Abnormal levels of alpha-fetoprotein may indicate a neural tube defect, such as spina bifida, or other chromosomal abnormalities.
Choice D rationale:
MSAFP determination is not used to screen for fetal maturity. It is used to assess the risk of certain fetal abnormalities.
Correct Answer is D
Explanation
Choice A rationale: Applying identification bands is an essential step in newborn care, but it is not the priority immediately after delivery. The nurse should first address the baby's physiological needs, such as drying and maintaining body temperature.
Choice B rationale: Assessing and documenting the Apgar score is important for evaluating the newborn's overall condition and response to delivery, but it is not the priority immediately after delivery.
Choice C rationale: Administering phytonadione (vitamin K) to prevent bleeding disorders in the newborn is essential, but it can be done after drying and stabilizing the baby's body temperature.
Choice D rationale: After ensuring a patent airway, the nurse's priority should be to dry the newborn. Drying the newborn is important for maintaining body temperature and preventing heat loss, especially during the immediate post-delivery period. Wet newborns can lose heat rapidly through evaporation, so drying the baby helps prevent hypothermia and stabilize the baby's body temperature.
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