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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 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.

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