help on this OB assessment question

newidea123 · Jun 17, 2009

What was their rational for A pal?, i thought it will have to be LOP, left ociput Posterior but am confused, i know the PMI, or baby can be felt most at it's back right?, am testing next week, hope we would get help be4 then, it may be one of my qxns, who knows haha!

Filerook · Jun 17, 2009

1. The nurse is caring for a client in labor. The nurse palpates a firm, round
form in the uterine fundus, small parts on the woman's R side and a long,
smooth, curved section on the L side. Based on these findings, the nurse
should anticipate auscultating the fetal heart in which of the following
locations?
A). L side below the umbilicus
B). L by the umbilicus
C). R below the umbilicus
D). R by the umbilicus
The answer Kaplan gives is A. However, I think B is right as the fetus is at breech. Anyone helps me out? Thanks!

I think the answer to your question lies in the precise wording of the suggested responses. The position of this baby would likely be either LST or LSA - left sacrum transverse, or left sacrum anterior (not LOP, as a previous poster mentioned, because the presenting part is the sacrum, not the occiput). I would expect to auscultate FHTs on the mother's left side, but probably NOT by the umbilicus, which would be more midline. So, while I agree that FHTs might be more likely to be heard above the umbilicus with a breech baby, they wouldn't be heard "by the umbilicus."

It really is a poorly worded, confusing question.

Valerie, former L&D RN

newidea123 · Jun 17, 2009

I see u are a L&D nurse, is this really how the fetus is assessed in the hospital. Anyway, i am testing next week and i have problem with this fetus diagrams, is there any way you can help me figure this things out once and for all? or atleast for the exam?, i will really appreiate and thank 4now,

lvn, reading for rn

I think the answer to your question lies in the precise wording of the suggested responses. The position of this baby would likely be either LST or LSA - left sacrum transverse, or left sacrum anterior (not LOP, as a previous poster mentioned, because the presenting part is the sacrum, not the occiput). I would expect to auscultate FHTs on the mother's left side, but probably NOT by the umbilicus, which would be more midline. So, while I agree that FHTs might be more likely to be heard above the umbilicus with a breech baby, they wouldn't be heard "by the umbilicus."
It really is a poorly worded, confusing question.
Valerie, former L&D RN

Filerook · Jun 17, 2009

I see u are a L&D nurse, is this really how the fetus is assessed in the hospital. Anyway, i am testing next week and i have problem with this fetus diagrams, is there any way you can help me figure this things out once and for all? or atleast for the exam?, i will really appreiate and thank 4now,
lvn, reading for rn

Heh, well, I am a former L&D nurse. I quit nursing for a few years in order to go to law school.

But when I was working, most of the nurses I knew really had very little experience with palpation. I don't believe I ever saw anyone use a fetoscope, and even a doppler was rare. Generally, laboring women would come in and be hooked up to the fetal monitor. My experience with palpation comes more from twenty years or so of being a homebirth midwife (yeah -- I was one of THOSE -- a subject for another time).

As to problems with "fetus diagrams," can you be more specific about what parts are giving you the most difficulty? Perhaps the best way to start is to keep in mind that the fetus can basically enter the pelvis in three different ways -- head first, butt first, or shoulder first. That is to say, breech, vertex, or transverse. If the baby is breech, the position is described by the relationship of the sacrum to the mother. Therefore, if the sacrum is towards the mothers front (anterior) the position would be SA - sacrum anterior. If the sacrum is towards the mother's back (posterior) it would be SP (sacrum posterior). If towards the left side of mother, it would be LST (left sacrum transverse - not to be confused with a tranverse lie, where the entire baby is lying crosswise in the uterus). If the baby's sacrum is towards the mother's left side and a little toward the front, it would be LSA (left sacrum anterior). The same rules apply to positions towards the mothers right side, and to posterior positions. The important thing to remember is that with a breech, the middle letter is always going to be an S, for sacrum.

With vertex babies, this "marker" is an O, for occiput, but the same rules apply.

So, another way to look at it is this way:

1. Is the baby head down or butt down?

2. Is the "marker" (actually officially called a "denominator" more towards the mother's left or right?

3. Is the "marker" more towards the mother's anterior or posterior.

So, for one more example -- let's look at LOP, which you referred to in your post.

For an LOP baby, we know from the O that this baby has to be head down. The L tells us that the occiput is towards the mother's left side, and the P lets us know that the occiput is also towards the mother's back.

For transverse lies, the denomimator is the scapula, abbreviated Sc, but I cannot even imagine that the NCLEX is going to get into something that obscure.

Anyway, I hope this is helpful -- if not, let me know and I will try to clarify!

Valerie

newidea123 · Jun 17, 2009

this is very helpful val, see, i'm a male nurse and was never into the L&B thing during clinicals, i once remembered a client refused me coming into her delivery area even though she agreed during the early stages of her labor process so since then i wasn't into it much. anyway thanks and will let you know if i have more qxns.

Filerook · Jun 17, 2009

this is very helpful val, see, i'm a male nurse and was never into the L&B thing during clinicals, i once remembered a client refused me coming into her delivery area even though she agreed during the early stages of her labor process so since then i wasn't into it much. anyway thanks and will let you know if i have more qxns.

I am glad it is helpful to you.

And I am sorry that your client refused your care during delivery. I do understand the client's right to choose (and refuse) caregivers, but it is too bad that it was - apparently - based on gender. Most of those same patients don't have a problem with male OBs.

When I worked L&D, the nurse in charge of our mother/baby unit education was male. He was a terrific nurse, but even he had occasional problems with patients (and doctors!) refusing his care.

Anyway, let me know if I can be of any further help.

Valerie

callenRN1507 · Jun 17, 2009

the nurse is caring for a client in labor. the nurse palpates a firm, round

form in the uterine fundus, small parts on the woman's r side and a long,

smooth, curved section on the l side. based on these findings, the nurse

should anticipate auscultating the fetal heart in which of the following

locations?

isn't it that when the presenting part is firm, and round that means that it is the head and not the bottom of the baby. as far as i know, there will be irregularities in the curve for a butt. so in the question it is the head that is the presenting part so it will not be in breech..now in checking the fetal heart rate, you need to locate the back of the fetus..in the question, the long, smooth curved section on the left side represents the back of the fetus so this is where you are going to auscultate the fetal heart rate..

based from what i have learned, the fetal heart rate is best heard on the upper back of a well flexed fetus..since the question did not mention the attitude of the fetus, judging from the choices youll only have 2 options, those are a. l side below the umbilicus or b. l side of the umbilicus.. with this i would say that the answer is a because as i have mentioned the fetal heart rate is best heard on the upper back of a well flexed fetus and if you are going to visulaize the fetus based from the scenario, this is where youll find its upper back.. so a. l side below the umbilicus

Filerook · Jun 17, 2009

the nurse is caring for a client in labor. the nurse palpates a firm, round
form in the uterine fundus, small parts on the woman's r side and a long,
smooth, curved section on the l side. based on these findings, the nurse
should anticipate auscultating the fetal heart in which of the following
locations?
isn't it that when the presenting part is firm, and round that means that it is the head and not the bottom of the baby. as far as i know, there will be irregularities in the curve for a butt. so in the question it is the head that is the presenting part so it will not be in breech..now in checking the fetal heart rate, you need to locate the back of the fetus..in the question, the long, smooth curved section on the left side represents the back of the fetus so this is where you are going to auscultate the fetal heart rate..
based from what i have learned, the fetal heart rate is best heard on the upper back of a well flexed fetus..since the question did not mention the attitude of the fetus, judging from the choices youll only have 2 options, those are a. l side below the umbilicus or b. l side of the umbilicus.. with this i would say that the answer is a because as i have mentioned the fetal heart rate is best heard on the upper back of a well flexed fetus and if you are going to visulaize the fetus based from the scenario, this is where youll find its upper back.. so a. l side below the umbilicus

hm...i agree that "firm and round" implies the head, but in the question it is said to be found in the uterine fundus, which means that it is not the presenting part. so i still feel that this baby is lst to lsa.

valerie

callenRN1507 · Jun 17, 2009

IC, I stand corrected, upon reading the question, yes it is a breech presentation and the FHR should be found on the L side above the umbilicus, not the other way around...

Jolie, BSN · Jun 17, 2009

I guess I'm the odd man out here. When I read the question, without looking at the choices, I said to myself, "lower L quadrant."

The description of a "firm, round form" in the uterine fundus was, to me, a description of the baby's butt. Since FHTs are heard best thru the baby's back, my thoughts were that the heart rate would be most easily auscultated on the mother's left side, below the umbilicus, where a term baby's torso would reach. I believe the question indicates a vertex presentation.

Filerook · Jun 18, 2009

I guess I'm the odd man out here. When I read the question, without looking at the choices, I said to myself, "lower L quadrant."
The description of a "firm, round form" in the uterine fundus was, to me, a description of the baby's butt. Since FHTs are heard best thru the baby's back, my thoughts were that the heart rate would be most easily auscultated on the mother's left side, below the umbilicus, where a term baby's torso would reach. I believe the question indicates a vertex presentation.

I can certainly see where one could conclude that -- sometimes it is hard to tell the difference between head and butt. But I guess the vast majority of baby butts I have palpated have been must more "irregular" feeling than heads, and not as hard and round. The question could have been written more clearly by simply adding "ballotable" to the description. That would have clearly indicated a head rather than a butt.

Valerie