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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The fracture does not cross through the bone. Choice A reason:
The statement in Choice A is incorrect because it describes a greenstick fracture as the bone bending and causing a microscopic fracture line. This is not true for a greenstick fracture. A greenstick fracture is an incomplete fracture where the bone bends and partially breaks on one side while remaining intact on the other side. The rationale for this is that pediatric bones are more flexible than adult bones, and when a force is applied, they tend to bend rather than completely break.
Choice B reason:
Choice B is the correct answer. A greenstick fracture does not cross through the bone; it involves only one side of the bone being broken while the other side remains intact. This type of fracture is common in children because their bones are still developing and contain more collagen, making them more flexible and prone to bending rather than breaking completely.
Choice C reason:
The statement in Choice C is incorrect because it describes a different type of fracture. A compressed fracture involves the bone being crushed or shortened, leading to a raised area at the fracture site. This is not characteristic of a greenstick fracture, which involves bending and partial breakage rather than compression.
Choice D reason:
The statement in Choice D is incorrect because it describes a complete fracture that completely divides the bone into two separate pieces. A greenstick fracture, as explained earlier, is an incomplete fracture and does not completely divide the bone.
Correct Answer is C
Explanation
Choice C reason: The infant makes babbling sounds. At 6 months of age, it is typical for infants to engage in babbling sounds. Babbling is a significant milestone in language development during infancy. It involves the repetition of consonant-vowel combinations (e.g., "ba-ba,”. "ma-ma") and is an essential precursor to later language skills, such as forming words and sentences. The nurse should expect the 6-month-old infant to be making these babbling sounds as part of their normal development.
Choice A reason:
The infant has a pincer grasp. A pincer grasp is the ability to pick up small objects using the thumb and index finger. This fine motor skill typically develops around 9 to 12 months of age. At 6 months old, infants have not yet acquired the pincer grasp. Therefore, the nurse should not expect the 6-month-old infant to demonstrate this skill during the assessment.
Choice D reason:
The infant crawls on their hands and knees. Crawling is a gross motor skill that usually emerges between 7 to 10 months of age. While some infants may start crawling earlier or later, it is not a skill that is typically present in a 6-month-old. Therefore, the nurse should not anticipate the 6-month-old infant to be crawling on their hands and knees during the assessment.
Choice B reason:
The infant drops objects with the expectation of someone picking them up. This behavior, known as "object permanence,”. is a cognitive milestone that develops around 8 to 12 months of age. At 6 months old, infants have not yet fully developed this concept. They might drop objects as part of their exploratory behavior, but they do not yet understand the expectation of someone picking them up. Therefore, the nurse should not expect the 6- month-old infant to exhibit this specific behavior during the assessment.
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