A nurse is assessing fetal heart tones for a client who is pregnant. The nurse has determined the fetal position as left occipital anterior. To which of the following areas of the client's abdomen should the nurse apply the ultrasound transducer to assess the point of maximum Intensity of the fetal heart?

Left upper quadrant

Right upper quadrant

Left lower quadrant

Right lower quadrant

Answer and Explanation

The Correct Answer is C

Choice A Reason:

Left upper quadrant is incorrect. The left upper quadrant is less likely to be the area where the point of maximum intensity of the fetal heart is heard when the fetal position is left occipital anterior.

Choice B Reason:

Right upper quadrant is incorrect. The right upper quadrant is not the typical location for assessing fetal heart tones when the fetal position is left occipital anterior. The heart tones are generally heard more towards the left side.

Choice C Reason:

Left lower quadrant is correct. Placing the ultrasound transducer in the left lower quadrant is likely to provide the best detection of the fetal heart tones in the described fetal position.

Choice D Reason:

Right lower quadrant is incorrect. Similar to the right upper quadrant, the right lower quadrant is not the optimal location for assessing the fetal heart when the fetal position is left occipital anterior. The left side is typically where the point of maximum intensity is found.

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Correct Answer is B

Explanation

The correct answer is B. Just above the symphysis pubis.

A. Just above the umbilicus: At the end of the first trimester, the uterus is still within the pelvic cavity, and fetal heart tones are typically not detectable above the umbilicus at this stage.

B. Just above the symphysis pubis: This is the correct placement for assessing fetal heart tones during the first trimester. The fetal heart is usually located low in the pelvis during early pregnancy, making it most easily heard just above the pubic bone.

C. The right lower quadrant: Fetal heart tones are typically assessed in the midline of the abdomen, and focusing on the lower quadrants may not be the optimal location, especially in the first trimester.

D. The left lower quadrant: Similar to the right lower quadrant, focusing on the lower quadrants may not be the most appropriate location for assessing fetal heart tones during the first trimester.

A. "I will receive this medication if my baby is Rh-negative." B. "I will receive this medication when I am in labor." C. "I will need a second dose of this medication when my baby is 6 weeks old." D. "I will need this medication if I have an amniocentesis."

Correct Answer is D

Explanation

Choice A Reason:

"I will receive this medication if my baby is Rh-negative." This statement does not record understanding of the teaching. The purpose of Rho(D) immune globulin is to prevent sensitization of an Rh-negative mother to Rh-positive fetal blood. If the baby is Rh-negative, there is no need for Rho(D) immune globulin.

Choice B Reason:

"I will receive this medication when I am in labor." This statement does not record understanding of the teaching. Rho(D) immune globulin is typically given around 28 weeks of pregnancy and possibly after events that could lead to mixing of maternal and fetal blood, not specifically during labor.

Choice C Reason:

"I will need a second dose of this medication when my baby is 6 weeks old." This statement does not record understanding of the teaching. The administration of Rho(D) immune globulin is generally based on events during pregnancy and delivery, and a second dose is not typically given postpartum unless the baby is Rh-positive.

Choice D Reason:

"I will need this medication if I have an amniocentesis." This statement records understanding of the teaching. Rho(D) immune globulin is given to Rh-negative women during pregnancy and certain other situations to prevent the development of Rh incompatibility with a Rh-positive baby. If the mother undergoes procedures such as amniocentesis or experiences events that could lead to mixing of maternal and fetal blood, Rho(D) immune globulin is administered.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is pregnant and is at the end of her first trimester. The nurse should place the Doppler ultrasound stethoscope in which of the following locations to begin assessing for the fetal heart tones (FHT)?

Correct Answer is B

Explanation

A nurse is teaching a client who is Rh negative about Rho(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding?

A nurse is creating the plan of care for a client who is at 39 weeks of gestation and in active labor. Which of the following actions should the nurse include in the plan of care?

A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first?

A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that she is, "happy one minute and crying the next." The nurse should interpret the client's statement as an indication of which of the following?

A nurse is planning discharge for a client who is 3 days postpartum. Which of the following nonpharmacological interventions should the nurse Include in the plan of care for lactation suppression?

A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (Select all that apply.)

A nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first?