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 B
Explanation
Choice A rationale: An increase in breast milk production is a normal physiological response during breastfeeding and does not indicate mastitis.
Choice B rationale: Mastitis is an inflammation of the breast tissue, usually caused by infection. It commonly occurs in breastfeeding women and is characterized by redness, warmth, swelling, and pain in one breast. The affected breast may also be tender and sore to the touch.
Choice C rationale: Swelling in both breasts is a common occurrence during the early days of breastfeeding as the milk supply adjusts to the baby's needs. It is not specific to mastitis.
Choice D rationale: Cracked and bleeding nipples can be a result of improper latch or positioning during breastfeeding, but they are not specific to mastitis.
Correct Answer is C
Explanation
Choice A rationale:
A gynaecoid pelvis is considered the most favorable pelvic shape for childbirth and is not a contributing cause of difficult, prolonged labor.
Choice B rationale:
A longitudinal fetal lie (baby's spine aligned with the mother's spine) is a normal and favorable presentation for birth and is not a contributing cause of difficult, prolonged labor.
Choice C rationale:
A persistent occiput posterior position (baby's head facing the mother's abdomen instead of her back) can be a contributing cause of difficult, prolonged labor and may lead to a severe backache for the mother.
Choice D rationale:
Fetal attitude in general flexion (baby's head flexed forward, chin to chest) is a normal and favorable presentation for birth and is not a contributing cause of difficult, prolonged labor.
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