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 B
Explanation
The correct answer is B. Just above the symphysis pubis.
A. Just above the umbilicus: At the end of the first trimester, the uterus is still within the pelvic cavity, and fetal heart tones are typically not detectable above the umbilicus at this stage.
B. Just above the symphysis pubis: This is the correct placement for assessing fetal heart tones during the first trimester. The fetal heart is usually located low in the pelvis during early pregnancy, making it most easily heard just above the pubic bone.
C. The right lower quadrant: Fetal heart tones are typically assessed in the midline of the abdomen, and focusing on the lower quadrants may not be the optimal location, especially in the first trimester.
D. The left lower quadrant: Similar to the right lower quadrant, focusing on the lower quadrants may not be the most appropriate location for assessing fetal heart tones during the first trimester.
Correct Answer is C
Explanation
Choice A Reason:
Reassess the client in 2 hours is inappropriate. While reassessment is important, addressing the cause of uterine displacement, in this case, a full bladder, should be the initial priority.
Choice B Reason:
Administering simethicone is inappropriate. Simethicone is typically used to relieve gas and bloating. It is not the primary intervention for uterine displacement related to bladder fullness.
Choice C Reason:
Assisting the client to empty her bladder is appropriate. A full bladder can displace the uterus and hinder its contraction, leading to potential issues such as uterine atony or increased postpartum bleeding. Emptying the bladder helps the uterus contract more effectively.
Choice D Reason:
Instructing the client to lie on her right side is inappropriate. Lying on the right side is often recommended to improve blood flow and oxygenation to the fetus during pregnancy but may not directly address uterine displacement caused by a full bladder. The priority is to assist the client in emptying her bladder.
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