A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. The nurse locates the fetal heart tones above the client’s umbilicus at midline. The nurse should suspect that the fetus is in which of the following positions?
Breech.
Transverse.
Cephalic.
Oblique.
The Correct Answer is A
Choice A rationale
Breech presentation means the fetus’s buttocks or feet are positioned to be delivered first. Fetal heart tones are often heard above the umbilicus in this position.
Choice B rationale
Transverse lie means the fetus is lying horizontally in the uterus. Fetal heart tones would typically be heard at the sides of the abdomen.
Choice C rationale
Cephalic presentation means the fetus’s head is positioned to be delivered first. Fetal heart tones are usually heard below the umbilicus in this position.
Choice D rationale
Oblique lie means the fetus is positioned diagonally in the uterus. Fetal heart tones can be variable depending on the exact position.
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View Related questions
Correct Answer is A
Explanation
Choice A rationale
A reactive non-stress test (NST) indicates that the fetal heart rate increases appropriately with fetal movements, suggesting good fetal oxygenation and neurological function. This is the desired outcome for an NST4.
Choice B rationale
A non-reactive NST means the fetal heart rate did not increase with movements, which could indicate fetal hypoxia or other issues. Further testing would be needed to assess fetal well-being.
Choice C rationale
An inconclusive NST means the test did not provide enough information to determine fetal well-being, possibly due to fetal sleep cycles or maternal factors. Additional testing would be required.
Choice D rationale
A positive NST is not a standard term used in fetal monitoring. The correct terms are reactive or non-reactive.
Correct Answer is B
Explanation
Choice A rationale
Uterine contractions that cause variable decelerations are not specific to true labor. Variable decelerations are typically associated with umbilical cord compression and can occur during both true and false labor.
Choice B rationale
Regular uterine contractions that cause cervical change are a definitive sign of true labor. True labor is characterized by contractions that become progressively stronger, more frequent, and more regular, leading to cervical dilation and effacement. This process indicates that the body is preparing for childbirth.
Choice C rationale
The station of the presenting part refers to the position of the fetus in relation to the ischial spines of the pelvis. While it is an important aspect of labor progression, it is not a definitive sign of true labor.
Choice D rationale
Rupture of the membranes, or the breaking of the water, can occur before true labor begins. While it often indicates that labor is imminent, it is not a definitive sign of true labor on its own.