A nurse is preparing to perform Leopold maneuvers on a client who is at 36 weeks of gestation. Identify the sequence of actions the nurse should take.

Position the client supine with knees flexed and place a small, rolled towel under one of their hips.

Palpate the fetal part positioned above the symphysis pubis.

Instruct the client to empty their bladder.

Palpate the fetal part positioned in the fundus.

Palpate the fetal parts along both sides of the uterus.

Answer and Explanation

The Correct Answer is C, A, D, E, B

The Leopold maneuvers are a common and systematic way to determine the position of a fetus inside the woman’s uterus. They are typically performed at prenatal examinations during the third trimester of pregnancy. Here is the correct sequence of actions a nurse should take: Instruct the client to empty their bladder. This is done to make the examination easier and more comfortable for the client ©. Position the client supine with knees flexed and place a small, rolled towel under one of their hips. This position helps relax the abdominal muscles and displaces the uterus to the side, reducing the risk of supine hypotensive syndrome (a). Palpate the fetal part positioned in the fundus. This helps determine the fetal lie and presentation (d). Palpate the fetal parts along both sides of the uterus. This helps identify the location of the fetal back and small parts (e). Palpate the fetal part positioned above the symphysis pubis. This helps determine the fetal attitude and degree of extension or flexion of the fetal head (b). Remember, these maneuvers should be performed gently and respectfully, with the nurse explaining each step to the client. The goal is to assess the position and presentation of the fetus, as well as estimate fetal weight, not to change the position of the fetus. If the nurse is unsure about the position or presentation of the fetus, an ultrasound may be needed for confirmation.

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Correct Answer is C

Explanation

Choice A rationale
Asking when the client last ate meat is not relevant for assessing dietary intake in a client who adheres to a vegan diet. Vegans do not consume meat or any other animal products.
Choice B rationale
While vitamin C is an important nutrient, it is not typically a concern for vegans as it is abundant in fruits and vegetables. Therefore, asking about vitamin C supplementation may not provide the most useful information about the client’s dietary intake.
Choice C rationale
Protein intake is a key concern for individuals following a vegan diet, as many sources of protein are animal-based. Vegans can get protein from foods like lentils, chickpeas, beans, tofu, and nuts. Therefore, asking about daily protein intake can provide valuable information about the client’s dietary habits and nutritional status.
Choice D rationale
Shellfish are not part of a vegan diet, so asking if the client has considered eating shellfish would not be relevant or appropriate.

A. Protective environment B. Droplet C. Contact D. Airborne .

Correct Answer is C

Explanation

Choice A rationale
A protective environment is not typically required for clients with MRSA141516. This type of precaution is usually used for clients who are severely immunocompromised and need to be protected from any potential sources of infection.
Choice B rationale
Droplet precautions are not typically used for clients with MRSA141516. These precautions are used for diseases that are spread through large respiratory droplets, such as influenza or pertussis.
Choice C rationale
Contact precautions are recommended for clients with MRSA141516. This involves using personal protective equipment and limiting patient movement outside of the room.
Choice D rationale
Airborne precautions are not typically used for clients with MRSA141516. These precautions are used for diseases that are spread through tiny airborne droplets, such as tuberculosis or chickenpox.

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A nurse is preparing to perform Leopold maneuvers on a client who is at 36 weeks of gestation. Identify the sequence of actions the nurse should take.

Nursing Test Bank

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