A healthcare provider is assessing fetal heart tones for a pregnant client. The provider has determined the fetal position as left occipital anterior. To which of the following areas of the client's abdomen should the provider apply the ultrasound transducer to assess the point of maximum intensity of the fetal heart?
- A. Left upper quadrant
- B. Right upper quadrant
- C. Left lower quadrant
- D. Right lower quadrant
Correct Answer: C
Rationale: The correct answer is C, left lower quadrant. In the left occipital anterior fetal position, the fetus's back is on the left side of the mother's abdomen. To assess the point of maximum intensity of the fetal heart tones, the ultrasound transducer should be applied to the area closest to the fetal back, which is the left lower quadrant. Applying the transducer in this area allows for optimal detection of the fetal heart sounds. Choices A, B, and D are incorrect as they are not in proximity to the fetal back in the left occipital anterior position, leading to suboptimal detection of fetal heart tones.
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A healthcare provider is discussing the differences between true labor and false labor with a group of expectant parents. Which of the following characteristics should the healthcare provider include when discussing true labor?
- A. Contractions become stronger with walking.
- B. Discomfort can be relieved with a back massage.
- C. Contractions become irregular with a change in activity.
- D. Discomfort is felt above the umbilicus.
Correct Answer: A
Rationale: The correct answer is A: Contractions become stronger with walking. This is because true labor is characterized by contractions that consistently increase in intensity and frequency, which is often enhanced by physical activity like walking. Contractions in false labor do not typically intensify with movement. Discomfort in true labor is usually not easily relieved by a back massage (B) and contractions in true labor remain regular even with changes in activity (C). Discomfort in true labor is typically felt in the lower abdomen and back, not above the umbilicus (D).
A client who is at 6 weeks of gestation is being educated about common discomforts of pregnancy. Which of the following findings should the individual include? (Select all that apply)
- A. Breast tenderness
- B. Urinary frequency
- C. Epistaxis
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. At 6 weeks of gestation, common discomforts include breast tenderness due to hormonal changes, urinary frequency from increased blood flow to kidneys, and epistaxis (nosebleeds) due to increased blood volume and vessel fragility. Therefore, all options are relevant and should be included in the education. Other choices are incorrect because they do not encompass all the common discomforts experienced during early pregnancy.
A client who is at 36 weeks of gestation and has a prescription for a nonstress test is being taught by a nurse. Which of the following statements should the nurse include in the teaching?
- A. You will receive IV fluid before this test.
- B. The procedure will take approximately 10 to 15 minutes.
- C. You will be offered orange juice to drink during the test.
- D. You will need to sign an informed consent form before each test.
Correct Answer: C
Rationale: The correct answer is C: "You will be offered orange juice to drink during the test." This statement is correct because providing orange juice to the client during the nonstress test can stimulate fetal movement, making it easier to monitor the baby's heart rate. This can help in obtaining a more accurate assessment of the baby's well-being.
Incorrect options:
A: IV fluid administration is not typically required for a nonstress test, so this statement is incorrect.
B: The procedure can actually take longer than 10 to 15 minutes, depending on various factors, so this statement is inaccurate.
D: Informed consent is usually obtained once, not before each test, so this statement is not necessary for the client to know in this context.
While assisting with the care of a client in active labor, a nurse observes clear fluid and a loop of pulsating umbilical cord outside the client's vagina. Which of the following actions should the nurse perform first?
- A. Place the client in the Trendelenburg position
- B. Apply finger pressure to the presenting part
- C. Administer oxygen at 10 L/min via a non-rebreather
- D. Call for assistance
Correct Answer: D
Rationale: The correct answer is D: Call for assistance. This is the first action the nurse should take in this emergency situation. Calling for help ensures that additional support and resources are available to manage the situation effectively. Placing the client in the Trendelenburg position (A) is not recommended as it can worsen the prolapsed cord. Applying finger pressure to the presenting part (B) can lead to further complications. Administering oxygen (C) may be necessary but is not the priority when a prolapsed cord is present.
In a prenatal clinic, a client in the first trimester of pregnancy has a health record that includes this data: G3 T1 P0 A1 L1. How should the nurse interpret this information? (Select all that apply)
- A. Client has delivered one newborn at term
- B. Client has experienced no preterm labor
- C. Client has had two prior pregnancies
- D. ALL OF THE ABOVE - has one living child
Correct Answer: D
Rationale: The data "G3 T1 P0 A1 L1" indicates the client has had 3 pregnancies (G3), 1 term delivery (T1), 0 preterm deliveries (P0), 1 living child (A1), and 1 living child currently (L1). Therefore, the correct interpretation is that the client has one living child (A1) from one term delivery (T1). Choice D ("ALL OF THE ABOVE - has one living child") is correct as it summarizes the information accurately. Choices A, B, and C are incorrect because they do not encompass all the aspects of the data provided in the client's health record.
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