A nurse is preparing to auscultate fetal heart tones for a client who is pregnant. Using Leopold maneuvers, the nurse palpates a round, firm, movable part in the fundal portion of the uterus and a long, smooth surface on the mother's right side. In which of the following maternal quadrants should the nurse auscultate fetal heart tones?

Right upper quadrant

Left lower quadrant

Right lower quadrant

Left upper quadrant

Answer and Explanation

The Correct Answer is A

Choice A rationale: Auscultating fetal heart tones in the right upper quadrant is not appropriate based on the information provided by Leopold maneuvers, which indicates the fetal back is on the right side of the mother's abdomen, and the fetal head is in the fundal portion of the uterus.
Choice B rationale: During Leopold maneuvers, the nurse palpated a round, firm, movable part in the fundal portion of the uterus. This finding corresponds to the fetal head, which is typically located at the top of the uterus (fundus). Additionally, the nurse palpated a long, smooth surface on the mother's right side. This finding indicates the fetal back, which typically lies along the right side of the mother's abdomen, suggesting that the fetus's back is positioned anteriorly (toward the mother's front). The location of the fetal heart is typically best heard over the back of the fetus. Therefore, the nurse should auscultate the fetal heart tones in the maternal quadrant corresponding to the back of the fetus, which is the left lower quadrant.
Choice C rationale: The information from Leopold maneuvers does not indicate the fetal back is in the right lower quadrant. The nurse should not auscultate fetal heart tones in this area.
Choice D rationale: Auscultating fetal heart tones in the left upper quadrant is not appropriate based on the information provided by Leopold maneuvers, which indicates the fetal head is in the fundal portion of the uterus and the fetal back is on the right side of the mother's abdomen. The fetal heart is usually best heard over the back of the fetus, which is not in the left upper quadrant.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale:
A 3-hour oral glucose tolerance test is typically done during the initial diagnosis of gestational diabetes, not for ongoing monitoring. Since the client is already diagnosed, this action is not necessary at this stage.
Choice B rationale:
Obtaining an HbA1C is not necessary in this situation. HbA1C provides information about average blood glucose levels over the past 2-3 months and is not specific to postprandial glucose levels.
Choice C rationale:
Telling the client to increase carbohydrates to 65% of daily nutritional intake would not be appropriate since the client already has elevated blood glucose levels. Reducing carbohydrate intake and focusing on a balanced diet are more appropriate for managing gestational diabetes.
Choice D rationale:
Given that the client's blood glucose levels after meals are consistently above the target range (generally <140 mg/dL for 1-hour post-meal), it indicates a need for better glycemic control, which may require insulin therapy.

A. Gestational hypertension B. Small for gestational age newborn C. Precipitous birth D. Two-vessel umbilical cord

Correct Answer is C

Explanation

Choice A rationale: While gestational hypertension can have various implications for the mother and baby, it is not directly associated with an increased risk of postpartum hemorrhage.
Choice B rationale: The birth of a small-for-gestational-age newborn may have certain implications, but it is not directly associated with an increased risk of postpartum hemorrhage.
Choice C rationale: Precipitous birth, which refers to an extremely rapid labor and delivery lasting less than 3 hours, is a risk factor for postpartum hemorrhage. Rapid delivery can lead to incomplete uterine contractions and inadequate uterine tone, increasing the risk of excessive bleeding after birth.
Choice D rationale: A two-vessel umbilical cord, also known as a single umbilical artery, may be associated with certain fetal anomalies but is not directly related to an increased risk of postpartum hemorrhage.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing laboratory results from a client who is at 28 weeks of gestation and has gestational diabetes. The nurse notes that blood glucose levels taken 1 hour following a meal range from 145 mg/dL to 162 mg/dL over the past week. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is reviewing the medical record of a client who experienced a vaginal birth 2 hr ago. The nurse should identify which of the following findings places the client at risk for a postpartum hemorrhage.

Correct Answer is C

Explanation

A nurse is assisting a nurse midwife in examining a client who is a primigravida at 42 weeks of gestation and states that she thinks she is in labor. Which of the following findings confirms that the client is in labor?

.A nurse is caring for a newborn who is formula-fed. The newborn takes 0.5 oz of formula at 0800, 1 oz at 1100, 0.5 oz at 1300, 0.5 oz at 1600, and 0.5 oz at 1830. How many mL of formula should the nurse record as the client's intake for the shift?

A nurse is caring for a postpartum client and her newborn. The client asks the nurse to feed the newborn. Which of the following responses should the nurse make?

A nurse is performing Leopold maneuvers on a client who is in labor and determines the fetus is in an RSA position. Which of the following fetal presentations should the nurse document in the client's medical record?

A nurse is collecting data from a newborn who weighs 5,160 g (11 lb, 6 oz) and whose mother has diabetes mellitus. For which of the following data should the nurse monitor?

A nurse is assisting in the care of a client who is in active labor. The nurse notes late decelerations on the fetal monitor tracing. Which of the following actions should the nurse take first?

A nurse is assisting a client with breastfeeding her newborn. The nurse should explain that which of the following reflexes will initiate sucking

A nurse is reinforcing teaching about strategies to calm a newborn with a client who is postpartum. Which of the following suggestions should the nurse make? (Select all that apply.)