The fetal heart rate is heard above the umbilicus and on the mother's left.
The nurse concludes that the fetus is in which position?
LSA.
LOA.
ROA.
ROP.
The Correct Answer is A
Choice A rationale
A fetus in the left sacroanterior (LSA) position has its sacrum, or buttocks, pointing toward the mother's left side and toward the front of her pelvis. The fetal heart is typically located in the fetal chest, and with a breech presentation (sacrum first), the fetal heart is located higher in the uterus, often above the umbilicus, which explains why the nurse hears the fetal heart rate in that location.
Choice B rationale
A fetus in the left occipitoanterior (LOA) position has its occiput, or back of the head, pointing toward the mother's left side and toward the front of her pelvis. In this vertex presentation, the fetal head is typically in the lower uterine segment, and the fetal heart would be heard below the mother's umbilicus, not above it.
Choice C rationale
A fetus in the right occipitoanterior (ROA) position has its occiput, or back of the head, pointing toward the mother's right side and toward the front of her pelvis. Similar to LOA, this is a vertex presentation. The fetal heart is typically heard below the mother's umbilicus and on her right side, not above it and on her left side.
Choice D rationale
A fetus in the right occipitoposterior (ROP) position has its occiput, or back of the head, pointing toward the mother's right side and toward the back of her pelvis. This is also a vertex presentation. The fetal heart would be heard below the mother's umbilicus and on her right side, not above it and on her left side.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Vacuum extraction involves applying a suction cup to the fetal scalp to assist with delivery. The pressure from the vacuum can cause a collection of blood between the periosteum and the skull, known as a cephalohematoma. This condition is confined to one cranial bone and does not cross suture lines. It typically resolves on its own over weeks to months.
Choice B rationale
A depressed fontanelle is a sign of dehydration or sunken sutures. In a vacuum-assisted delivery, the opposite often occurs, with the suction creating a "chignon" or caput succedaneum (scalp swelling) that can make the fontanelles appear full or even bulging, but not depressed. A depressed fontanelle is not a complication of this procedure.
Choice C rationale
A ruptured uterus is a rare but severe complication of labor. While it can be associated with oxytocin use or a history of previous uterine surgery, it is not a direct complication of vacuum extraction itself. The risk factors for uterine rupture are different and not directly related to the application of the vacuum cup to the fetal head.
Choice D rationale
Down syndrome is a chromosomal disorder (trisomy 21) that occurs at conception. It is not caused by labor or delivery methods, including vacuum extraction. This is a congenital condition resulting from an extra copy of chromosome 21. A vacuum delivery has no impact on the genetic makeup of the fetus.
Correct Answer is D
Explanation
Choice A rationale
The statement, "I am glad they are giving me something to try to stop my labor for now," shows a correct understanding of nifedipine's role as a tocolytic agent. Nifedipine, a calcium channel blocker, works by inhibiting the influx of calcium into uterine muscle cells, which is necessary for contraction. This effectively slows or stops preterm labor, giving time for corticosteroids to work.
Choice B rationale
The statement, "This medication can lower my blood pressure to dangerous levels," shows a correct understanding of a major side effect of nifedipine. As a calcium channel blocker, it causes vasodilation, which can lead to a drop in blood pressure. The patient should be monitored for hypotension and advised to report symptoms like dizziness or lightheadedness.
Choice C rationale
The statement, "I will let you know if I feel dizzy," indicates a correct understanding of a common symptom associated with the hypotensive effect of nifedipine. Dizziness is a direct result of decreased cerebral blood flow due to lower blood pressure. Reporting this symptom allows the nurse to intervene and prevent falls or other complications.
Choice D rationale
The statement, "Nifedipine should help mature my baby's lungs," is incorrect. Nifedipine is a tocolytic used to stop uterine contractions. The medication used to promote fetal lung maturity is a corticosteroid, such as betamethasone. This statement indicates a need for additional teaching to differentiate the purpose of these two classes of medications.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.