A nurse is assisting in the care of a client who is in labor and requires intermittent fetal monitoring. Which of the following actions should the nurse take?
Auscultate fetal heart tones during a contraction.
Place a Doppler ultrasound over the fundus.
Perform Leopold maneuvers to determine fetal position.
Count the fetal heart rate for 15 seconds.
The Correct Answer is C
Choice A rationale
Auscultating fetal heart tones during a contraction does not provide a clear assessment of the fetal heart rate pattern and can be affected by the contraction itself.
Choice B rationale
Placing a Doppler ultrasound over the fundus is not effective, as the fundus is not the optimal location to hear fetal heart tones, especially in early labor.
Choice C rationale
Performing Leopold maneuvers to determine fetal position is crucial as it helps in placing the Doppler in the correct position for accurate monitoring of fetal heart tones.
Choice D rationale
Counting the fetal heart rate for 15 seconds and then multiplying by 4 may not provide an accurate assessment of the fetal heart rate pattern or variability, which is important for fetal well-being assessment. .
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is C
Explanation
Choice A rationale
The newborn's legs flexing at the knees and hips when pressure is applied to the soles indicates the stepping reflex, an expected response.
Choice B rationale
Newborns do not typically keep their eyes closed when tapped on the forehead; this is not an expected reflex response.
Choice C rationale
The palmar grasp reflex, where the newborn's fingers curl around the nurse's finger, is an expected and normal finding in newborns, indicating healthy neurological function.
Choice D rationale
The rooting reflex, where the newborn turns their head when their cheek is touched, is expected and demonstrates feeding readiness and normal neural development. .
Correct Answer is B
Explanation
Choice A rationale
Carrots, while nutritious and rich in vitamins, are not a significant source of iron. They provide fiber and beta-carotene but do not meet the increased iron needs during pregnancy.
Choice B rationale
Chicken breast is an excellent source of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant-based foods. Consuming chicken breast helps in meeting the increased iron requirements during pregnancy.
Choice C rationale
Apples are healthy and provide essential nutrients and fiber but are not a significant source of iron. They contribute to overall well-being but do not address the specific need for increased iron intake.
Choice D rationale
Feta cheese is a good source of calcium and protein but not iron. While it contributes to nutritional intake during pregnancy, it does not help in meeting the increased iron needs.