NCLEX-PN
2024 PN NCLEX Questions Questions
Extract:
Question 1 of 5
A nurse is determining the fetal heart rate (FHR) and places the fetoscope on the mother's abdomen to count the FHR. The nurse simultaneously palpates the mother's radial pulse and notes that it is synchronized with the sounds heard through the fetoscope. Which action should the nurse take?
Correct Answer: B
Rationale: When auscultating the fetal heart rate, the nurse would place the fetoscope on the maternal abdomen, over the fetal back. The nurse would then palpate the mother's radial pulse. If her pulse is synchronized with the sounds from the fetoscope, the nurse would move the fetoscope to another area on the mother's abdomen to locate the FHR. The nurse needs to be sure that the FHR is what is actually being heard. Other sounds that may be heard are the funic sound (blood flowing through the umbilical cord) and the uterine sound (blood flowing through the uterine vessels). The funic sound is synchronized with the FHR; the uterine sound is synchronized with the mother's pulse.
Therefore, moving the fetoscope to a different area will help in accurately locating and counting the fetal heart rate.
Choice A is incorrect because counting for 60 seconds without changing the position may not address the issue of accurately locating the FHR.
Choice C is incorrect as it does not address the need to reposition the fetoscope to locate the fetal heart.
Choice D is incorrect because counting the FHR and the radial pulse rate separately may not help in differentiating the two sounds.
Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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