31. A nurse is preparing to perform Leopold maneuvers on a client who is at 36 weeks of gestation. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps)
Position the client supine with knees flexed and place a small rolled towel under one of their hips.
Palpate the fetal part positioned in the fundus.
Instruct the client to empty their bladder.
Palpate the fetal parts along both sides of the uterus.
Palpate the fetal part positioned above the symphysis pubis.
The Correct Answer is C,A,B,D,E
C. Instruct the client to empty their bladder.
A. Position the client supine with knees flexed and place a small rolled towel under one of their hips.
B. Palpate the fetal part positioned in the fundus.
D. Palpate the fetal parts along both sides of the uterus.
E. Palpate the fetal part positioned above the symphysis pubis.
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Related Questions
Correct Answer is D
Explanation
Rationale:
A. Administering oxygen via a nonrebreather mask may be indicated for fetal distress, but the priority in this situation is to protect the umbilical cord from compression and minimize fetal compromise.
B. Cover the umbilical cord with a sterile saline-saturated towel is an appropriate action to prevent the cord from drying out and to reduce infection butimmediate focus should be on relieving pressure on the umbilical cord to ensure adequate fetal perfusion.
C. Initiate an infusion of IV fluids for the client can help stabilize maternal hemodynamics, but it does not directly address the umbilical cord compression. Relieving the pressure on the cord is the immediate intervention to prevent fetal hypoxia.
D. Perform a vaginal examination by applying upward pressure on the presenting part is the priority intervention. In cases of umbilical cord prolapse, the nurse must perform a vaginal examination and apply upward manual pressure on the presenting part (usually the fetal head) to lift it off the umbilical cord. This action relieves compression on the cord and restores blood flow and oxygen delivery to the fetus until an emergency delivery can be performed.
Correct Answer is C
Explanation
Rationale:
A. Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, typically in the fallopian tube. This scenario does not match the clinical presentation described.
B. Incompetent cervix is characterized by painless cervical dilation in the second trimester and is not relevant to the clinical situation described.
C. Postpartum hemorrhage is a risk when a woman is in advanced labor with significant cervical dilation. The nurse should be vigilant for signs of hemorrhage during labor and after delivery.
D. Hyperemesis gravidarum is severe nausea and vomiting during pregnancy and is not directly related to the client's current labor status.
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