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 A
Explanation
The nurse should inform the client that it is common for yellow discharge to form at the circumcision site during the first 24 to 72 hours following the procedure. This is due to the accumulation of exudate, which is a normal part of the healing process. The nurse does not need to obtain a sample of the discharge for laboratory testing. The povidone-iodine solution should not be applied to the circumcision site, as it can be caustic and delay healing. Wiping the discharge away gently with a washcloth and warm water may irritate the wound and cause additional trauma.
Correct Answer is A
Explanation
May 13. Nägele's Rule is used to calculate the estimated date of delivery (EDD) based on the first day of the last menstrual period (LMP). To use this rule, the nurse subtracts 3 months from the first day of the LMP and adds 7 days and 1 year.
For this client, the first day of her LMP was August 10. Subtracting 3 months gives us May 10. Adding 7 days gives us May 17. Adding 1 year gives us May 17, 2022. Therefore, the estimated date of delivery is May 17, 2022.
It is important to note that Nägele's Rule is an estimation, and not all pregnancies follow the typical 280-day gestational period. Other factors, such as irregular menstrual cycles, can affect the accuracy of the estimated date of delivery. The nurse should monitor the client's pregnancy and adjust the estimated date of delivery as needed based on ultrasound results and other clinical findings.
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