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 A
Explanation
Choice A rationale: During phototherapy, it is essential to maintain adequate hydration and nutrition for the newborn. Encouraging frequent breastfeeding helps provide the baby with essential nutrients and fluids, which can be lost due to increased stooling caused by phototherapy.
Choice B rationale: The use of lotion on the newborn's skin during phototherapy is not recommended, as it may interfere with the effectiveness of the light therapy. The skin needs to be exposed to the light for the treatment to work.
Choice C rationale: Monitoring the newborn's blood glucose level is not directly related to phototherapy. Blood glucose monitoring may be necessary for specific medical reasons, but it is not a standard intervention during phototherapy.
Choice D rationale: During phototherapy, the newborn is usually placed in a supine (face-up) position to ensure maximum exposure of the skin to the phototherapy lights. The prone position is not recommended during phototherapy as it may reduce the effectiveness of the treatment.
Correct Answer is C
Explanation
Choice A rationale: A breech presentation means that the baby's buttocks or feet are the presenting part, not the shoulder.
Choice B rationale: Vertex presentation refers to a head-down position of the baby with the occiput (back of the head) as the presenting part. In the RSA position, the baby is in vertex presentation, but the specific part facing the mother's right side is the shoulder.
Choice C rationale: RSA (Right Sacrum Anterior) indicates that the fetus is in a vertex presentation with the head pointing down and the back of the baby's head (occiput) facing the mother's right side. The shoulder is the presenting part of this position.
Choice D rationale; Mentum refers to the chin of the baby. A mentum presentation (also called face presentation) means that the baby's face is the presenting part, not the shoulder.
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