A nurse is auscultating fetal heart tones with a Doppler device for a client who is at 12 weeks of gestation. Where should the nurse expect to auscultate the fetal heart tones?
Umbilical area
Suprapubic area
Above the left iliac crest
Below the liver border on the right abdomen
The Correct Answer is C
Rationale:
A) Incorrect - The umbilical area is not a typical location for auscultating fetal heart tones.
B) Incorrect - The suprapubic area is not a common location for auscultating fetal heart tones.
C) Correct - At 12 weeks of gestation, the nurse would typically auscultate the fetal heart tones above the left iliac crest, which is in the lower abdomen. This is where the uterus is located at this stage of pregnancy.
D) Incorrect - Auscultating below the liver border on the right abdomen is not a standard practice for fetal heart tone assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect- A reddened area on the calf might indicate a potential blood clot (deep vein thrombosis), which is important to assess but may not be the highest priority.
B) Incorrect- Painful uterine contractions during breastfeeding can be a normal response due to oxytocin release during breastfeeding and might not require immediate reporting.
C) Correct - A urinary output of 125 mL in 4 hours is significantly low and could indicate inadequate fluid intake, potential urinary retention, or other issues that need prompt attention. It is a sign of impaired renal function. This could indicate dehydration, blood loss, infection, or kidney injury. The nurse should assess the client's fluid intake and output, vital signs, urine specific gravity, and serum electrolyte levels. The nurse should also monitor the client for signs of hypovolemia, such as tachycardia, hypotension, and decreased skin turgor.
D) Incorrect- Changing a perineal pad every 2 hours is within the normal range for postpartum bleeding and might not require immediate reporting.
Correct Answer is B
Explanation
A) Incorrect- Elevating a baby's head with a cushion during sleep is not recommended, as it can increase the risk of sudden infant death syndrome (SIDS) and obstructed breathing.
B) Correct - "I should replace the batteries in my smoke detector twice per year." Regularly replacing smoke detector batteries helps ensure they function properly in case of a fire emergency.
C) Incorrect- Setting the hot water heater to 130°F (54.4°C) is too hot and can cause scalding burns. The recommended temperature is 120°F (48.9°C) or lower.
D) Incorrect- Baby powder is not recommended for use with diaper changes, as it can be inhaled by the baby and lead to respiratory issues.
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