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 D

Explanation

Choice A reason:

Insomnia may not be an expected finding in a school-age child with a newly diagnosed brain tumor. While sleep disturbances can occur due to various medical conditions, insomnia is not a common presenting symptom of brain tumors in this age group. Thus, it is less likely to be the correct answer.

Choice B reason:

A negative Babinski sign would actually be a normal finding in a school-age child. The Babinski sign is a neurological test that becomes positive in certain conditions, but a negative result is expected in a healthy child. Therefore, this finding is not indicative of a brain tumor and is not the correct choice.

Choice C reason:

Increased appetite is also an unlikely finding in a child with a newly diagnosed brain tumor. Brain tumors can lead to various neurological symptoms, but an increased appetite is not a characteristic feature. Thus, this choice is less likely to be correct.

Choice D reason:

Incoordination is a more expected finding in a school-age child with a newly diagnosed brain tumor. Brain tumors can affect motor skills and coordination due to their location and impact on the brain's functions. Children may experience difficulties with balance, coordination, and fine motor skills. Therefore, this choice is the most likely correct answer.

A. Administer glucocorticoids. B. Monitor the client's temperature. C. Give calcium gluconate. D. Prepare the client for an amniocentesis.

Correct Answer is B

Explanation

Choice A reason: Following the rupture of membranes, delivery is imminent and administration of glucocorticoids may not take effect to benefit the baby.

Choice B reason:

Monitoring the client's temperature (Choice B) is important as the client is at risk of chorioamnionitis which may increase the risk of severe early neonatal sepsis. Changes in temperature as they may warrant anibiotic therapy and immediate delivery.

Choice C reason:

Giving calcium gluconate (Choice C) is not indicated in this situation. Calcium gluconate is typically administered in cases of magnesium sulfate toxicity or to treat hypocalcemia, neither of which is mentioned in the scenario. Therefore, it is not the appropriate action for the nurse to take at this time.

Choice D reason:

Preparing the client for an amniocentesis (Choice D) is not the correct action in this situation. An amniocentesis is a procedure in which a small amount of amniotic fluid is withdrawn for various diagnostic reasons, such as genetic testing or assessing fetal lung maturity. However, in this scenario, the priority is to administer glucocorticoids to promote fetal lung maturity, and an amniocentesis does not address this immediate concern.

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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?

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