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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
One cup of oatmeal - Oatmeal is a nutritious food, but it does not contain as high a protein content as some other options. While it offers some protein, it is not the best choice for a high-protein diet during pregnancy. Oatmeal is primarily known for its fiber content and complex carbohydrates, which provide sustained energy.
Choice B reason:
One cup of tofu - Tofu is an excellent source of protein and is a suitable choice for a high- protein diet during pregnancy. Tofu is made from soybeans and is rich in plant-based proteins, making it an ideal option for individuals following a vegetarian or vegan diet as well. Additionally, tofu contains essential amino acids, iron, calcium, and other nutrients beneficial for both the mother and the developing fetus.
Choice C reason:
One cup of brown rice - While brown rice is a healthy whole grain and provides some protein, it does not have as high a protein content as tofu. Brown rice is a good source of complex carbohydrates, fiber, vitamins, and minerals, but it may not meet the high protein requirements of a pregnant woman's diet.
Choice D reason:
One cup of kale - Kale is a nutritious leafy green vegetable, but it does not offer a significant amount of protein compared to tofu. It is rich in vitamins, minerals, and antioxidants, making it a valuable addition to a balanced diet. However, for a high-protein diet during pregnancy, other options like tofu are more suitable.
Correct Answer is A
Explanation
The nurse should maintain continuous observation of the adolescent.
Choice A reason:
The first and most crucial action when a patient expresses an intention to self-harm is to ensure their safety. By maintaining continuous observation, the nurse can closely monitor the adolescent's behavior and intervene promptly if any signs of self-harm emerge. This action helps prevent immediate harm and allows for timely interventions.
Choice B reason:
Applying wrist restraints to the adolescent (Choice B) would not be appropriate in this situation. Restraints are typically used as a last resort for patients who pose a danger to themselves or others and only when less restrictive measures have failed. In the case of self- harm, using restraints can increase the patient's distress and potentially worsen the situation.
Choice C reason:
Collecting data about the adolescent's mental status (Choice C) is an essential step in understanding their overall condition, but it should not be the first action taken. While gathering data is important for a comprehensive assessment, immediate safety concerns must take precedence.
Choice D reason:
Obtaining consent from the adolescent's guardian for the application of restraints (Choice D) is not the first priority when the patient expresses an intention to self-harm. The focus should be on ensuring the patient's immediate safety, and consent for restraints may be necessary only if other interventions prove inadequate.
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