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 D
Explanation
Choice A rationale
While changes in an infant’s sleep patterns can be a sign of many issues, they are not a specific indicator of a food allergy.
Choice B rationale
Rice cereals are typically one of the first foods introduced to infants and are usually well- tolerated. They are not known to cause problems during lactation.
Choice C rationale
The foods a mother eats can affect breast milk, but they do not typically cause food allergies. Most babies can tolerate a variety of foods in a mother’s diet without any problems.
Choice D rationale
If there is a strong family history of peanut allergies, the mother might want to avoid eating peanuts while breastfeeding. However, current research suggests that early exposure to potential allergens may actually decrease the risk of developing allergies.
Correct Answer is C
Explanation
Choice A rationale
The Babinski reflex is a normal reflex in infants that disappears by 12 months of age. It involves fanning out of the toes when the sole of the foot is stroked, and it doesn’t promote latching during breastfeeding.
Choice B rationale
The stepping reflex is a primitive reflex that makes newborns appear to take steps or dance when held upright with their feet touching a solid surface. It doesn’t promote latching during breastfeeding.
Choice C rationale
The rooting reflex helps promote latching during breastfeeding. When the corner of the baby’s mouth is touched, the baby will turn his or her head and open his or her mouth to follow and “root” in the direction of the stroking. This helps the baby find the breast or bottle to start feeding.
Choice D rationale
The Moro reflex, also known as the startle reflex, involves the baby throwing back his or her head, extending out the arms and legs, crying, then pulling the arms and legs back in. It doesn’t promote latching during breastfeeding.
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