12. During the assessment of a client who is in labor, a nurse notes that the fetal heart tones are loudest in the upper right quadrant. The infant is most likely in which position?
12. During the assessment of a client who is in labor, a nurse notes that the fetal heart tones are loudest in the upper right quadrant. The infant is most likely in which position?
. Right sacrum anterior presentation.
. Right occipital anterior presentation.
. Left sacrum anterior presentation.
. Left occipital transverse presentation.
Test-Taking Tip
Divide the maternal abdomen into four quadrants. Hearing the heart tones loudest in the upper quadrant is usually associated with breech presentation; note the word "sacrum."
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Assessment; Cognitive Level: Application; Client Need/Subneed: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
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Answer 1 is correct because right sacrum anterior (RSA) means that the fetal sacrum is closest to the mother's symphysis and rotated slightly to the mother's right; therefore, the heart tones would be loudest in the upper right quadrant. Answer 2 is incorrect because a right occipital anterior presentation would have loudest fetal heart tones in the lower right quadrant. Answer 3 is incorrect because in a left sacrum anterior presentation the fetal sacrum is closest to the mother's symphysis and rotated slightly to the mother's left; therefore, the heart tones would be loudest in the upper left quadrant. Answer 4 is incorrect because a left occipital transverse presentation would have loudest fetal heart tones in the lower left quadrant.