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, Ensure the newborn's eyes are closed beneath the shield. Phototherapy is a treatment used to reduce high bilirubin levels in newborns. It involves exposing the newborn's skin to special lights, which helps to break down the excess bilirubin in the blood. It is important to ensure that the newborn's eyes are closed beneath the shield to prevent damage to the eyes from the bright lights. Giving the newborn 1 oz of glucose water every 4 hr, applying lotion to the newborn's skin every 8 hr, and dressing the newborn in a thin layer of clothing during therapy are not indicated interventions during phototherapy.
Correct Answer is B
Explanation
A. Monitor the rectal temperature every 4 hr: Rectal temperature measurement is contraindicated in this newborn due to the risk of trauma to the spinal cord or irritation of the leaking sac. Axillary temperature monitoring is a safer alternative.
B. Administer broad-spectrum antibiotics: Broad-spectrum antibiotics help prevent infection from organisms entering through the exposed or leaking sac. This is a priority intervention to ensure the safety of the newborn.
C. Cleanse the site with povidone-iodine: Povidone-iodine is not recommended for cleansing the sac, as it can cause irritation or toxicity. Instead, the sac should be kept clean and moist with a sterile, saline-soaked dressing.
D. Prepare for surgical closure after 72 hr: Surgical closure of the defect is typically performed within 24 to 48 hours after birth to minimize infection risk and prevent further damage to neural tissue. Waiting beyond this window is not standard practice for a leaking myelomeningocele.
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