A nurse is assessing a client who is at 39 weeks of gestation and determines that the fetus is in a left occipitoanterior position. On which of the following sites should the nurse place the external fetal monitor to hear the point of maximum impulse of the fetal heart rate?
Right upper quadrant
left upper quadrant
left lower quadrant.
right lower quadrant.
The Correct Answer is C
A. This would be appropriate if the fetus were in a breech presentation.
B. This is incorrect because the fetal back is in the lower left quadrant, not the upper quadrant.
C. In the Left Occipitoanterior (LOA) Position, the fetal occiput (back of the head) is facing the mother’s left side and anteriorly (toward the front of the uterus). The fetal back will be on the left side of the maternal abdomen, making the PMI in the left lower quadrant. The best location to place the fetal monitor is over the fetal back, closest to the head. Since the fetus is cephalic (head down) in LOA position, the heart sounds are heard in the left lower quadrant.
D. This would be appropriate if the fetus were in a right occipitoanterior (ROA) position, but in LOA, the back is on the left.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C, the client who has hyperemesis gravidarum and a sodium level of 110 mEq/L should be assessed first. This client's low sodium level indicates hyponatremia, which can lead to seizures and brain damage if not corrected promptly. The nurse should assess the client's neurologic status, including level of consciousness, reflexes, and motor function, and notify the provider immediately. The other clients also require close monitoring and intervention, but their conditions are not as urgent as the client with hyponatremia. Clients with preeclampsia require monitoring of blood pressure and kidney function, clients with placenta previa require monitoring of bleeding and hematocrit levels, and clients with diabetes mellitus require monitoring of blood glucose levels and HbA1c.
Correct Answer is B
Explanation
A. This option is incorrect because the development of breast tissue in newborns is not directly related to the mother’s hormone levels during pregnancy. Newborns typically have breast buds regardless of maternal hormone variations.
B. A flat areola with no breast bud is a characteristic finding in preterm newborns. Breast tissue development is one of the physical markers used to assess gestational age, and the lack of a breast bud is an indicator of immaturity, suggesting a preterm gestational age.
C. Ambiguous secondary sex characteristics are not related to the presence or absence of breast buds in newborns. This option focuses on sexual development rather than gestational markers.
D. A flat areola with no breast bud is a normal finding in preterm infants and does not indicate a congenital anomaly. This condition is expected in preterm newborns based on their developmental stage.
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