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?
Left lower
Right upper
Left upper
Right lower
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Avoiding sexual relations for 3 days is not sufficient advice for a client diagnosed with a sexually transmitted infection (STI). The client should abstain from sexual activity until they and their partner(s) have completed treatment and are symptom-free.
Choice B rationale
Even if a sexual partner has no symptoms, they could still be infected and require treatment. Many STIs can be asymptomatic, meaning they do not show symptoms, but can still be transmitted to others.
Choice C rationale
Returning in 6 months for retesting is a good practice for individuals diagnosed with an STI. Some infections, like chlamydia and gonorrhea, should be retested about 3 months after treatment. Other infections, like HIV, might need a follow-up test 6 months later to confirm the results.
Choice D rationale
The treatment for STIs varies depending on the specific infection. Not all STIs are treated with a single dose of erythromycin. For example, gonorrhea is typically treated with an injection of ceftriaxone and oral azithromycin.
Correct Answer is B
Explanation
The correct answer is choiceB. Expressions of excitement.
Choice A rationale:
Eagerness to learn newborn care skills is more characteristic of the “taking-hold” phase, which follows the “taking-in” phase.During the taking-hold phase, the mother becomes more independent and starts to take an active role in caring for her newborn.
Choice B rationale:
Expressions of excitement are typical during the “taking-in” phase. This phase occurs in the first 1-2 days postpartum, where the mother is primarily focused on herself and her birth experience.She may be excited and talkative about the birth process.
Choice C rationale:
Focus on the family unit and its members is more aligned with the “letting-go” phase, which is the final phase of maternal postpartum adjustment.In this phase, the mother starts to integrate the newborn into the family and adjusts to her new role.
Choice D rationale:
Lack of appetite can occur during the “taking-in” phase due to exhaustion and the physical demands of labor, but it is not a defining characteristic of this phase.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.