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
Ceftriaxone (Rocephin) is an antibiotic that is often used to treat bacterial infections, but it is not typically the first line of treatment for herpes.
Choice B rationale
Penicillin G intravenously is a type of antibiotic that is often used to treat bacterial infections. However, herpes is a viral infection, and antibiotics are not effective against viruses.
Choice C rationale
Acyclovir is an antiviral medication that is commonly used to treat herpes infections. It works by slowing the growth and spread of the herpes virus in the body. This would be the most appropriate treatment for a patient presenting with symptoms of a herpes outbreak.
Choice D rationale
Betamethasone is a type of corticosteroid that is often used to reduce inflammation. While it might help to reduce some of the inflammation and discomfort associated with herpes lesions, it would not address the underlying viral infection.
Correct Answer is A
Explanation
Choice A rationale
Placing the client in a lateral position can help improve blood flow to the uterus and placenta, which can help stabilize the client’s blood pressure and the fetal heart rate.
Choice B rationale
Monitoring vital signs every 5 minutes is important, but the priority action is to address the client’s low blood pressure, which can compromise blood flow to the fetus.
Choice C rationale
Elevating the client’s legs can help increase venous return and improve blood pressure, but it is not the priority action in this situation.
Choice D rationale
Notifying the provider is important, but the nurse should first take action to stabilize the client’s condition.
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