Nokea
The nurse is about to auscultate an FHR on the client in triage. What information should the nurse determine first in order to find the correct placement for auscultation?
- A. Position of the fetus
- B. Position of the placenta
- C. Presence of contractions
- D. Where to apply the ultrasonic gel
Correct Answer: A
Rationale: The nurse should first perform Leopold’s maneuvers to determine the fetal position. This will enable proper placement of the Doppler device over the location of the FHR. The position of the placenta can provide important information. However, if the Doppler device is placed over the placenta, the nurse will hear a swishing sound and not the FHR. The FHR is still assessed regardless of the presence of contractions. The nurse who has difficulty obtaining an FHR because of a contraction can listen again once the contraction has concluded. Ultrasonic gel is used with any ultrasound device and allows for the conduction of sound and continuous contact of the device with the maternal abdomen. In order to apply the gel to the correct location, the position of the fetus must be known.
You may also like to solve these questions
The client who is actively bleeding due to a spontaneous abortion asks the nurse why this is happening. The nurse advises the client that the majority of first-trimester losses are related to which problem?
- A. Cervical incompetence
- B. Chronic maternal disease
- C. Poor implantation
- D. Chromosomal abnormalities
Correct Answer: D
Rationale: Chromosomal abnormalities account for the majority of first-trimester spontaneous abortions. Cervical incompetence can result in spontaneous abortion but does not account for the majority. Chronic maternal disease can result in spontaneous abortion but does not account for the majority. Poor implantation can result in spontaneous abortion but does not account for the majority.
What information should the nurse also include about the side effects of iron supplementation?
- A. You may notice that your stools will be black.
- B. Your teeth will become stained.
- C. Vomiting is likely to occur.
- D. You may have diarrhea several times per day.
Correct Answer: A
Rationale: Black stools are a common side effect of iron supplements due to unabsorbed iron, unlike the other options.
The delivery nurse is reporting to the postpartum nurse about the client who just delivered her first baby, a term newborn. Which number should the delivery nurse report for the client’s parity?
Correct Answer: 1
Rationale: The client has given birth to her first child; her parity is 1.
Multiple women are being seen in a clinic for various conditions. From which clients should the nurse prepare to obtain a group beta streptococcus (GBS) culture? Select all that apply.
- A. The client who is having symptoms of preterm labor
- B. The women who had a neonatal death 1 year ago
- C. All pregnant women coming to the clinic for care
- D. The women who had a spontaneous abortion 1 week ago
- E. The women who had an abortion for an unwanted pregnancy
Correct Answer: A,C
Rationale: The client in preterm labor should be screened for GBS infection. Between 10% and 30% of all women are colonized for GBS. All pregnant women, regardless of risk status, should be screened for GBS infection. Between 10% and 30% of all women are colonized for GBS. There is no indication that the client with a previous neonatal death is pregnant. The client would not be screened for GBS solely because of a history of spontaneous abortion. The client would not be screened for GBS solely because of an elective abortion.
The client who is 32 weeks pregnant asks how the nurse will monitor the baby’s growth and determine if the baby is “really okay.” Which assessments should the nurse identify for evaluating the fetus for adequate growth and viability? Select all that apply.
- A. Auscultate maternal heart tones.
- B. Measure the height of the fundus.
- C. Measure the client’s abdominal girth.
- D. Complete a third-trimester ultrasound.
- E. Auscultate the fetal heart tones (FHT).
Correct Answer: B,E
Rationale: Adequate fetal growth is evaluated by measuring the fundal height. Auscultating the FHT assesses fetal viability. The presence of fetal (not maternal) heart tones starting at around 10-12 weeks is a standard to assess fetal growth and viability. The abdominal circumference does not provide information about fetal growth. The increase in abdominal girth could be due to weight gain or fluid retention, not just growth of the baby. Third-trimester ultrasound is neither routine nor advised for routine prenatal care because of the added cost and potential risk to the fetus.