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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: Stopping breastfeeding is not an appropriate response to breast engorgement. Continuing to breastfeed frequently and effectively can help relieve the engorgement and ensure adequate milk supply.
Choice B rationale: While frequent breastfeeding is beneficial for both the baby and mother, this statement does not directly address breast engorgement.
Choice C rationale: Wearing a supportive bra during the daytime can actually help reduce breast engorgement and discomfort by providing gentle pressure and support to the breasts.
Choice D rationale: Breast engorgement is a common issue for breastfeeding mothers, especially during the early days after delivery. Applying cold compresses to the breasts before each feeding can help reduce swelling and discomfort associated with engorgement, making it easier for the baby to latch onto the breast.
Correct Answer is A
Explanation
Choice A rationale: This statement indicates that the client understands the teaching about managing hyperemesis gravidarum. Eating crackers before getting out of bed in the morning is a common strategy to help alleviate morning sickness and hyperemesis gravidarum. Eating small, bland, and easily digestible foods before rising from bed can help prevent nausea and vomiting.
Choice B rationale: Drinking water with meals is not a specific strategy for managing hyperemesis gravidarum. In some cases, consuming liquids with meals might worsen nausea in clients with severe morning sickness.
Choice C rationale: Limiting protein intake is not a recommended strategy for managing hyperemesis gravidarum. Adequate protein intake is essential during pregnancy for proper fetal development.
Choice D rationale: Eating every 6 hours might not be sufficient for managing hyperemesis gravidarum. Frequent, small meals and snacks are often recommended to help manage nausea and vomiting in pregnancy.
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