What could be the result of fetal head compression?

Uteroplacental insufficiency.

Spontaneous rupture of membranes.

Altered fetal cerebral blood flow.

Umbilical cord compression.

Answer and Explanation

The Correct Answer is A

Choice A rationale: Uteroplacental insufficiency causes late decelerations due to reduced oxygenation, not mechanical pressure. It reflects placental dysfunction, not direct cranial compression effects.

Choice B rationale: Spontaneous rupture of membranes increases infection and labor risk but does not directly alter cerebral perfusion or trigger vagal responses linked to head compression.

Choice C rationale: Altered fetal cerebral blood flow results from cranial pressure during contractions, triggering vagal stimulation and early decelerations. This is the physiological response to head compression.

Choice D rationale: Umbilical cord compression causes variable decelerations due to transient blood flow obstruction, unrelated to cranial pressure or cerebral perfusion changes.

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Correct Answer is D

Explanation

Choice A rationale
The left lower quadrant is not the most likely location to auscultate fetal heart tones if the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client’s right side. These findings suggest that the fetus is in a breech position with its back on the left side, which would place the fetal chest, and thus the heart tones, in the right lower quadrant.
Choice B rationale
The right upper quadrant is not the most likely location to auscultate fetal heart tones if the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client’s right side. These findings suggest that the fetus is in a breech position with its back on the left side, which would place the fetal chest, and thus the heart tones, in the right lower quadrant.
Choice C rationale
The left upper quadrant is not the most likely location to auscultate fetal heart tones if the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client’s right side. These findings suggest that the fetus is in a breech position with its back on the left side, which would place the fetal chest, and thus the heart tones, in the right lower quadrant.
Choice D rationale
The right lower quadrant is the most likely location to auscultate fetal heart tones if the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on

the client’s right side. These findings suggest that the fetus is in a breech position with its back on the left side, which would place the fetal chest, and thus the heart tones, in the right lower quadrant.

A. Administer oxytocin infusion. B. Evaluate the firmness of the uterus. C. Initiate oxygen therapy by non-rebreather mask. D. Obtain a type and crossmatch.

Correct Answer is B

Explanation

Choice A rationale
Administering oxytocin infusion is usually done to stimulate uterine contractions and prevent postpartum hemorrhage. However, it’s not the first action to take when the client’s blood pressure is low.

Choice B rationale
Evaluating the firmness of the uterus is crucial in this situation. A soft or “boggy” uterus could indicate uterine atony, a condition that can lead to serious postpartum hemorrhage. This could be the cause of the client’s low blood pressure.
Choice C rationale
Initiating oxygen therapy by non-rebreather mask can help increase the client’s oxygen saturation levels, but it doesn’t address the underlying cause of the low blood pressure.
Choice D rationale
Obtaining a type and crossmatch is important if the client needs a blood transfusion. However, it’s not the first action to take. The nurse should first assess for possible causes of the low blood pressure.

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What could be the result of fetal head compression?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client’s right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones?

Correct Answer is D

Explanation

A nurse is caring for a client who gave birth 2 hours ago. The nurse notes that the client’s blood pressure is 60 mm Hg. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

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