The labor and delivery nurse caring for a client at 39 weeks gestation notes that the fetal heart tone is heard most loudly and clearly when auscultated in the upper right abdominal quadrant above the umbilicus.
What is the nurse's best interpretation of this finding?
The fetus may be in a breech presentation.
The fetus is likely in the left occiput anterior position.
The fetus may have polyhydramnios.
The fetus is likely in the right occiput posterior position.
The Correct Answer is A
Choice A rationale
When the fetal heart tones are heard loudest in the upper right abdominal quadrant above the umbilicus, it suggests that the fetal back, which transmits sound most clearly, is located in that area. In a breech presentation, the fetal buttocks or feet are in the lower uterine segment, and the head is in the upper portion of the uterus. Therefore, the fetal heart sounds would be best auscultated in the upper abdomen.
Choice B rationale
In the left occiput anterior (LOA) position, the fetal occiput is in the left anterior quadrant of the maternal pelvis. The fetal heart tones are typically heard loudest in the lower left quadrant of the maternal abdomen because the fetal back is usually anterior and slightly to the left.
Choice C rationale
Polyhydramnios is an excessive amount of amniotic fluid. While it can sometimes make it more difficult to auscultate fetal heart tones clearly due to increased fluid volume, it does not directly correlate with the location where the heart tones are heard loudest. The position of the fetus is the primary determinant of the auscultation location.
Choice D rationale
In the right occiput posterior (ROP) position, the fetal occiput is in the right posterior quadrant of the maternal pelvis. The fetal heart tones would typically be heard loudest in the lower right quadrant of the maternal abdomen, as the fetal back would be positioned posteriorly and to the right.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While addressing the client's pain is important, the priority action should be to assess the underlying cause of the concerning vital signs before offering pain medication.
Choice B rationale
Positioning the client with one hip elevated is a measure used to relieve potential vena cava compression, but the low blood pressure warrants immediate attention and further evaluation before implementing this intervention.
Choice C rationale
Having the client void may be a helpful intervention in some labor situations, but the combination of a low maternal blood pressure and a high maternal heart rate requires immediate notification of the provider.
Choice D rationale
The client's low blood pressure (82/54 mm Hg) and elevated maternal heart rate (128/min) in the presence of contractions with a duration of 1 minute and a frequency of 3 minutes are concerning findings that warrant immediate notification of the provider for further evaluation and management. These vital signs could indicate maternal hypovolemia, dehydration, or other complications. .
Correct Answer is D
Explanation
Choice A rationale
While assessing cervical dilation is important for understanding the progress of labor, it is not the priority intervention in the case of umbilical cord prolapse. The immediate danger is fetal oxygen deprivation due to compression of the prolapsed cord. Delaying intervention to perform a cervical exam could worsen fetal hypoxia.
Choice B rationale
Increasing the rate of intravenous fluids might be indicated to support maternal blood pressure and placental perfusion, but it does not directly address the immediate problem of cord compression. The priority is to relieve pressure on the umbilical cord to restore fetal oxygen supply.
Choice C rationale
Administering oxygen to the mother is a helpful supportive measure to increase the oxygen available to the fetus. However, it does not directly relieve the compression on the umbilical cord, which is the immediate life-threatening situation for the fetus.
Choice D rationale
Repositioning the mother to a knee-chest position (or Trendelenburg) uses gravity to help relieve pressure on the prolapsed umbilical cord by moving the presenting part of the fetus away from the pelvis. This is the priority nursing intervention as it directly aims to improve fetal oxygenation by reducing cord compression until the fetus can be delivered. .
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