A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow. (Move the steps, placing them in the order of performance. Use all the steps.)

Identify the attitude of the head.

Palpate the fundus to identify the fetal part.

Determine the location of the fetal back.

Palpate for the fetal part presenting at the inlet

Answer and Explanation

The Correct Answer is B, C, D, A

B. Palpate the fundus to identify the fetal part. This step helps determine which part of the fetus is in the upper part of the uterus (fundus), usually the head or buttocks. C. Determine the location of the fetal back. This step involves palpating the sides of the abdomen to locate the fetal back, which feels firm and smooth, and the small parts (limbs), which feel irregular and knobby. D. Palpate for the fetal part presenting at the inlet. This step helps identify the part of the fetus that is above the pelvic inlet, usually the head or buttocks. A. Identify the attitude of the head. This final step involves determining the position and attitude of the fetal head,which helps assess the degree of flexion or extension.

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Correct Answer is D

Explanation

The correct answer is d.

A. Informing the client that the anesthetic effect will last for approximately 6 hours is not the nurse's responsibility. The anesthesia provider usually communicates this information to the client.

B. Administering a 500 mL bolus of 5% dextrose in water prior to induction is the correct action.

Although preloading with a 500–1,000 mL bolus of isotonic crystalloid (e.g., Lactated Ringer’s) is recommended to mitigate hypotension, dextrose‑containing solutions (like D5W) are not used for this preload.

C. Having the client stand at the bedside with her arms at her side is not necessary for the administration of epidural analgesia. The client is usually positioned sitting up or lying on her side during the procedure.

D. Before initiating epidural analgesia, you must establish a baseline fetal heart rate and uterine contraction pattern with at least 20–30 minutes of continuous EFM to ensure fetal well‑being and detect any decelerations or atypical patterns.

A. Instruct the client to increase her respiratory rate to more than 42 breaths per min. B. Assist the client to breathe into a paper bag C. Have the client tuck her chin to her chest. D. Administer oxygen via nasal cannula

Correct Answer is C

Explanation

A. Instructing the client to increase her respiratory rate to more than 42 breaths per minute may exacerbate hyperventilation and cause respiratory alkalosis. This is not the appropriate action in this situation.

B. Breathing into a paper bag is an outdated and potentially dangerous practice. It can lead to a buildup of carbon dioxide in the body and may have adverse effects on both the mother and the baby. It is not recommended.

C. Having the client tuck her chin to her chest is the correct action.

This maneuver helps decrease the respiratory rate and prevent hyperventilation. It promotes a controlled and appropriate breathing pattern during labor.

D. Administering oxygen via nasal cannula is not the first-line intervention for lightheadedness and tingling during labor. The client's symptoms are likely due to hyperventilation, and addressing the breathing pattern is more appropriate.

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A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow. (Move the steps, placing them in the order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a client who is in active labor for epidural analgesia. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who is in the first stage of labor and is using pattern-paced breathing. The client says she feels lightheaded and her fingers are tingling. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is planning care for a client who is 2 hr postpartum. Which of the following interventions should the nurse plan to implement during the taking-hold phase of postpartum behavioral adjustment?

A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that she is, "happy one minute and crying the next." The nurse should interpret the client's statement as an indication of which of the following?

A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify?

A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client's history should the nurse recognize as a contraindication to oral contraceptives? (Select all that apply)

A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not. Which of the following should the nurse recognize as a sign of true labor?

A nurse is caring for a client who is experiencing preterm labor at 29 weeks of gestation and has a prescription for betamethasone. Which of the following statements should the nurse make about the indication for medication administration?