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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
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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