The nurse is preparing to assess the fetus of a laboring client. ...

[fagboi]

The nurse is preparing to assess the fetus of a laboring client. Which should the nurse perform first?
 
  1. Place the client into a left lateral position.
  2. Perform the Leopold maneuver to determine fetal position.
  3. Dry the maternal abdomen before using the Doppler.
  4. Count the fetal heart rate for 30 seconds and multiply by 2.

Question 2

The nurse is preparing to assess a client who has just arrived in the labor and birth unit. Which statement indicates that additional education is needed?
 
  1. When you check my cervix, you will find out how thinned out it is.
  2. After you assess my pelvis, you will be able to tell when I will deliver.
  3. You are going to do a vaginal examination to see how far dilated my cervix is.
  4. The reason for a pelvic examination is to determine how low in the pelvis my baby is.

[katheyjon]

Answer to Question 1

2
Explanation:
1. The fetal heart tone assessment should be performed while the client is either supine with a lateral tilt or while in left lateral position.
2. Leopold maneuvers are performed first to determine where to listen for fetal heart tones. This is the first step so that the Doppler device can be placed directly over the heart and multiple unsuccessful attempts to hear the heart rate are avoided.
3. Prior to using the Doppler device, a water-based gel is applied to the skin.
4. Although this is how to auscultate the fetal heart rate, it is better to perform Leopold maneuvers to determine fetal position so that the Doppler device can be placed directly over the heart and multiple unsuccessful attempts to hear the heart rate are avoided.

Answer to Question 2

2
Explanation:
1. Cervical effacement, or the thinning of the cervix, is one aspect of the pelvic examination assessment.
2. An experienced labor and birth nurse can estimate the time of delivery based on the cervix, fetal position, station, and contraction pattern. However, during a pelvic examination, no information is obtained about the contractions. The nurse will not have enough information following the cervical examination to estimate time of birth.
3. Cervical dilation is one aspect of the pelvic examination assessment.
4. Determining the station of the presenting part is one aspect of the pelvic examination assessment.