A nurse is planning to assist with Leopold maneuvers on a client who is at 37 weeks of gestation. Which of the following actions should the nurse plan to take?
Ask the client to empty their bladder.
Assist the client into a left-lateral position.
Apply an external fetal monitor to the clients abdomen.
Instruct the client to perform nipple stimulation.
Able to move from back to front.
Correct Answer : A,B,C
Choice A reason: The nurse should plan to ask the client to empty their bladder before performing Leopold maneuvers. The rationale behind this is to ensure that the client's bladder is empty to allow for better palpation of the uterus and fetal position. A full bladder can interfere with accurate assessment and may lead to incorrect findings during the examination.
Choice B reason:
The nurse should assist the client into a left-lateral position. This position is ideal for performing Leopold maneuvers because it helps to displace the uterus away from the vena cava, reducing the risk of supine hypotension syndrome. Moreover, the left-lateral position promotes optimal blood flow to the placenta, which is essential for the well-being of the fetus during the examination.
Choice C reason:
The nurse should apply an external fetal monitor to the client's abdomen after completing the Leopold maneuvers. The purpose of Leopold maneuvers is to determine the fetal position and presentation manually. Once this information is obtained, applying the external fetal monitor allows continuous monitoring of the fetal heart rate and uterine contractions to assess the baby's well-being and the progression of labor.
Choice D reason:
The nurse should not instruct the client to perform nipple stimulation when planning to assist with Leopold maneuvers. Nipple stimulation is a method to induce or augment labor, and it is not related to the process of assessing fetal position and presentation using Leopold maneuvers. It may lead to unnecessary contractions and confusion during the examination.
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Related Questions
Correct Answer is A
Explanation
Abdominal distention. Choice A reason:
Abdominal distention is a common manifestation of Hirschsprung's disease in infants. This condition is characterized by the absence of ganglion cells in the distal segment of the colon, leading to a functional obstruction. The absence of ganglion cells causes the affected part of the colon to become narrow and unable to relax, resulting in a buildup of stool and gas, leading to abdominal distention.
Choice B reason:
Steatorrhea, which is the presence of fatty, bulky, and foul-smelling stools, is not typically associated with Hirschsprung's disease. This manifestation is more commonly seen in conditions affecting the pancreas, liver, or small intestine, where the digestion and absorption of fats are impaired.
Choice C reason:
Blood-tinged emesis (vomiting) is not a typical manifestation of Hirschsprung's disease. This symptom is more commonly associated with gastrointestinal bleeding, which can be caused by various factors such as ulcers, esophageal varices, or gastritis.
Choice D reason:
Dysphagia, which refers to difficulty swallowing, is also not a characteristic manifestation of Hirschsprung's disease. Dysphagia is more commonly seen in conditions affecting the esophagus or throat, such as esophageal strictures or neurological disorders affecting swallowing reflexes.
Correct Answer is ["A"]
Explanation
Choice A reason: The correct answer is choice A. The nurse should expect the presence of the Moro reflex in a 6-month-old infant. The Moro reflex is a normal primitive reflex seen in infants up to about 6 months of age. When the infant experiences a sudden loss of support or a loud noise, they react by extending their arms and legs and then pulling them back in, as if trying to grasp onto something. This reflex is an important indicator of the baby's neurological development.
Choice B reason:
The birth weight doubling by 6 months of age is a typical growth milestone for infants. However, this statement is not correct in the context of the question, as it is not something the nurse should "expect” during a well-child visit. Instead, it is a general developmental milestone that healthcare providers monitor over time.
Choice C reason:
The correct answer is choice C. The nurse should expect the posterior fontanel to be closed in a 6-month-old infant. Fontanels are soft spots on a baby's skull that allow for brain growth during early development. The posterior fontanel, located at the back of the head, is typically closed by 6 months of age.
Choice D reason:
The correct answer is choice D. At 6 months of age, many infants can sit unsupported. However, not all infants achieve this milestone at the exact same age. Some may achieve it a bit earlier, while others might take a little more time. It is essential for the nurse to assess the infant's developmental progress and provide appropriate guidance to the parents.
Choice E:
The correct answer is choice E. By 6 months of age, some infants may be able to move from their back to their front. This is usually accomplished through rolling over. However, like other developmental milestones, the age at which infants achieve this can vary. Therefore, while the nurse may expect this ability in some infants, it is not something that all 6-month- old infants will have mastered at the time of the well-child visit.
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