Maternity Nursing: Antepartum Q 52
A nurse-midwife is performing an assessment of a pregnant client and is assessing the client for the presence of ballottement. Which of the following would the nurse implement to test for the presence of ballottement?
A. Auscultating for fetal heart sounds.
B. Palpating the abdomen for fetal movement.
C. Assessing the cervix for thinning.
D. Initiating a gentle upward tap on the cervix.
Correct Answer: D. Initiating a gentle upward tap on the cervix.
Ballottement is a technique of palpating a floating structure by bouncing it gently and feeling it rebound. In the technique used to palpate the fetus, the examiner places a finger in the vagina and taps gently upward, causing the fetus to rise. The fetus then sinks, and the examiner feels a gentle tap on the finger.
Option A: There are two methods of fetal heart rate monitoring in labor. Auscultation is a method of periodically listening to the fetal heartbeat. Electronic fetal monitoring is a procedure in which instruments are used to continuously record the heartbeat of the fetus and the contractions of the woman’s uterus during labor.
Option B: The Leopold maneuvers, named after the German obstetrician and gynecologist Christian Gerhard Leopold (1846–1911), are part of the physical examination of pregnant women. Four classical maneuvers are used to palpate the gravid uterus systematically. This method of abdominal palpation is of low cost, easy to perform, and non-invasive. It is used to determine the position, presentation, and engagement of the fetus in utero.
Option C: Effacement means that the cervix stretches and gets thinner. Dilatation means that the cervix opens. As labor nears, the cervix may start to thin or stretch (efface) and open (dilate). This prepares the cervix for the baby to pass through the birth canal (vagina).