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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?

A.

Auscultate fetal heart tones during a contraction.

B.

Place a Doppler ultrasound over the fundus.

C.

Perform Leopold maneuvers to determine fetal position.

D.

Count the fetal heart rate for 15 seconds.

Answer and Explanation

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. .


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View Related questions

Correct Answer is B

Explanation

Choice A rationale

Wearing an underwire bra is not recommended for clients with inverted nipples as it can cause discomfort and restrict milk flow. Proper support without constriction is essential.

Choice B rationale

Placing breast shells in the client's bra helps to draw out inverted nipples by applying gentle pressure, making breastfeeding easier. They also protect the nipples from friction and irritation.

Choice C rationale

Providing plastic-lined breast pads may prevent leakage, but they do not address the issue of inverted nipples. Proper nipple preparation is essential for effective breastfeeding.

Choice D rationale

Applying breast cream regularly might keep the skin hydrated, but it does not help to correct the inversion of the nipples. Mechanical aids like breast shells are more effective.

Correct Answer is A

Explanation

Choice A rationale

Assisting the client's partner to apply counterpressure to the sacrum can help alleviate the low-back pain associated with early labor by providing direct pressure to the area experiencing discomfort.

Choice B rationale

Maintaining the client on bed rest until active labor begins is not typically recommended, as mobility can help with the progression of labor and pain management.

Choice C rationale

Inserting an indwelling urinary catheter is not necessary for managing low-back pain in early labor and can increase the risk of infection and discomfort.

Choice D rationale

Teaching the client to hold their breath during contractions is not advisable, as it can lead to increased pain and decreased oxygenation for both the mother and baby. Breathing techniques are usually recommended to manage pain and ensure adequate oxygen delivery. .

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