A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. The nurse locates the fetal heart tones above the client's umbilicus at midline. The nurse should suspect that the fetus is in which of the following positions?
Frank breech
Cephalic
Posterior
Transverse
The Correct Answer is A
A. Frank breech position
A. In a frank breech presentation, the baby's buttocks are the presenting part. When the nurse locates fetal heart tones above the client's umbilicus at midline during active labor, it is indicative of a breech presentation, and the frank breech position is one possibility.
B. In a cephalic presentation, which is the most common and ideal position for childbirth, the fetal head is the presenting part, and the fetal heart tones would typically be heard below the umbilicus.
C. In a posterior position, the back of the baby's head is against the mother's spine. Fetal heart tones in this position would be typically heard below the umbilicus.
D. In a transverse lie, the baby is positioned horizontally across the uterus. Fetal heart tones may be heard laterally in this position, not necessarily above the umbilicus at midline.
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Related Questions
Correct Answer is C
Explanation
The correct answer is C. Place the client in a lateral position.
A. Elevating the client's legs is not the priority in this situation. Placing the client in a lateral position is more appropriate to improve blood flow and prevent supine hypotension.
B. Notifying the provider is an important action but not the immediate priority. Addressing the client's position and blood pressure is crucial before contacting the provider.
C. Placing the client in a lateral position is the priority nursing action.
The low blood pressure may be due to aortocaval compression (supine hypotension) caused by the weight of the uterus on the vena cava. Turning the client onto her side alleviates this compression and helps improve blood flow.
D. Monitoring vital signs every 5 minutes is important, but the immediate action should be to address the client's position and blood pressure. Continuous monitoring and further interventions can follow.
Correct Answer is D
Explanation
The correct answer is D. Variable decelerations.
A. Accelerations in the fetal heart rate are generally considered reassuring. Accelerations are an indication of fetal well-being and are often seen in response to fetal movement.
B. Early decelerations are typically associated with head compression during contractions and are considered a normal response to the pressure on the fetal head.
C. Late decelerations are indicative of uteroplacental insufficiency.
Late decelerations occur after the peak of the contraction and are associated with inadequate oxygenation to the fetus. This pattern raises concerns about the baby's well-being.
D. Variable decelerations are associated with umbilical cord compression.
Variable decelerations are abrupt decreases in the fetal heart rate that vary in duration, depth, and timing. They often coincide with contractions and suggest compression or occlusion of the umbilical cord.
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