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.

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A reason:

Airborne precautions are implemented for diseases that spread through small airborne particles, such as tuberculosis or measles. These diseases can remain suspended in the air for extended periods and be inhaled by others. Pertussis, also known as whooping cough, is primarily spread through respiratory droplets when an infected person coughs or sneezes, making airborne precautions unnecessary.

Choice B reason:

Droplet precautions are appropriate for illnesses that spread through respiratory droplets produced when an infected person talks, coughs, or sneezes. Pertussis falls into this category as it is transmitted mainly through respiratory droplets. By implementing droplet precautions, the nurse will minimize the risk of transmission to others, including healthcare workers and other patients.

Choice C reason:

Standard precautions are the baseline infection prevention practices used for all patients to prevent the spread of infections in healthcare settings. While important, they may not be sufficient to control the transmission of pertussis, as it requires additional measures like droplet precautions due to its specific mode of transmission.

Choice D reason:

Neutropenic precautions are used for patients with compromised immune systems, particularly those with low white blood cell counts (neutropenia). The purpose is to protect these vulnerable individuals from exposure to infectious agents. However, pertussis precautions are different and do not fall under the neutropenic category.

A. Adolescents tend to be more concerned with their appearance than the dying process. B. Many adolescents imagine death as a type of monster. C. Adolescents tend to believe their own actions might have caused their terminal illness. D. Many adolescents don't understand that death is permanent.

Correct Answer is A

Explanation

Adolescents tend to believe their own actions might have caused their terminal illness. Choice A reason:

This statement reflects a common developmental focus for adolescents, who are often navigating issues related to identity and self-image. While they are aware of their illness, many may prioritize concerns about how they look and how they are perceived by others. This can be a significant aspect of their experience during a terminal illness.

Choice B reason:

Many adolescents imagine death as a type of monster. Although this statement acknowledges a common perception of death among some adolescents, it is not the best choice for reinforcing teaching about the perception of death in the context of a terminal illness. The focus should be on more concrete and realistic aspects of death and its implications.

Choice C reason:

This statement does reflect a valid concern but may not be as prevalent as the concern with appearance in this age group. Many adolescents, especially in a terminal situation, may focus on more immediate concerns, such as how they are perceived.

Choice D reason:

Many adolescents don't understand that death is permanent. While this statement may be true for some adolescents who are still developing a full comprehension of death, it is not the most suitable choice for this scenario. In the context of a terminal illness, it is essential to acknowledge that the adolescent likely has a clear understanding of the finality of death.

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