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

Answer and Explanation

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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Correct Answer is C

Explanation

The correct answer is C.

A. Calcium: While calcium is important for bone health, it is not specifically increased during early pregnancy. Adequate calcium intake is important throughout pregnancy, but the focus on increased intake typically occurs later in pregnancy to support fetal bone development.

B. Vitamin E: Vitamin E is important for overall health, but there is not a specific emphasis on increasing vitamin E intake in the early stages of pregnancy. It is generally included as part of a balanced diet.

C. Iron: This is the correct answer. Iron needs increase during pregnancy to support the increased blood volume and prevent iron-deficiency anemia. Adequate iron is crucial for the transport of oxygen to the developing fetus.

D. Vitamin D: While vitamin D is important for bone health and immune function, its increase is not specific to the early stages of pregnancy. Adequate vitamin D intake is essential throughout pregnancy, but it is not singled out as needing a significant increase at 8 weeks of gestation.

A. Increase the oxytocin infusion to 13 mu/min B. Place client in a side lying position C. Initiate bolus of primary IV fluids D. Apply oxygen at 10 L/Min via venturi mask E. Perform sterile vaginal examination (SVF) F. Assign a bishop score G. Perform an amniotomy

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"B"},"G":{"answers":"A"}}

Explanation

Increase the oxytocin infusion to 13 mu/min:

Anticipated: This action is anticipated. Adjusting the oxytocin infusion rate may be appropriate based on the progress of labor and the response to the current infusion rate.

Place client in a side-lying position:

Anticipated: Placing the client in a side-lying position is an anticipated action. This position can enhance fetal oxygenation and blood flow, especially if there are concerns about fetal well-being.

Initiate a bolus of primary IV fluids:

Anticipated: Initiating a bolus of primary IV fluids is an anticipated action. Adequate hydration is important during labor, and a bolus may be initiated if there are signs of dehydration or as part of the overall management plan.

Apply oxygen at 10 L/Min via a venturi mask:

Anticipated: Applying oxygen at 10 L/min via a venturi mask is an anticipated action. Oxygen may be administered to the mother to improve oxygenation and, consequently, fetal oxygenation.

Perform sterile vaginal examination (SVE):

Contraindicated: There is no indication for a sterile vaginal examination (SVE) at this time based on the information provided. Frequent unnecessary SVEs can increase the risk of infection.

Assign a Bishop score:

Nonessential: Assigning a Bishop score is not essential at this point. The client's cervical status was assessed during admission, and the current focus is on monitoring the progress of labor with oxytocin.

Perform an amniotomy:

Anticipated: Depending on the clinical situation, performing an amniotomy (artificial rupture of membranes) may be anticipated as part of the labor induction process. However, the decision should be based on the overall assessment and progress of labor.

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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?

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Correct Answer is C

Explanation

A nurse is caring for a client who is 42 weeks of gestation. Exhibits Based on the assessment findings, which of the following actions should the nurse plan to take? Click to specify whether the nurse's planned actions are anticipated, nonessential, or contraindicated

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"B"},"G":{"answers":"A"}}

Explanation

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