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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Administering an IV bolus of lactated Ringer’s is not the best action for a client with peripartum cardiomyopathy. This condition is a form of heart failure that occurs during the last month of pregnancy or up to five months postpartum. It can lead to fluid overload, so giving an IV bolus of lactated Ringer’s could exacerbate the client’s condition.
Choice B rationale
Assessing blood pressure twice daily is important for any postpartum client, but it is not the most critical action for a client with peripartum cardiomyopathy. This condition can lead to fluid overload and heart failure, so while monitoring blood pressure is important, it is not the primary intervention.
Choice C rationale
Restricting daily oral fluid intake is the correct action. Peripartum cardiomyopathy can lead to fluid overload and heart failure. Restricting fluid intake can help manage the client’s fluid status and prevent exacerbation of heart failure.
Choice D rationale
Obtaining a prescription for misoprostol is not relevant in this context. Misoprostol is a medication used to prevent stomach ulcers in patients taking NSAIDs and to induce labor or cause an abortion. It has no role in the management of peripartum cardiomyopathy.
Correct Answer is A
Explanation
Choice A rationale
The newborn’s symptoms of jitteriness, weak cry, mottled extremities with acrocyanosis, and rapid, unlabored respirations are indicative of hypoglycemia. Hypoglycemia in the newborn period can be caused by several factors, including maternal diabetes (gestational or pre- existing), preterm birth, and sepsis. The nurse should take actions to address this condition, such as ensuring the newborn is warm, initiating early feeding to provide the newborn with glucose, and monitoring blood glucose levels.
Choice B rationale
Neonatal Abstinence Syndrome (NAS) is a group of problems that occur in a newborn who was exposed to addictive opiate drugs while in the mother’s womb. NAS can cause a wide range of symptoms such as excessive crying, poor feeding, and seizures. However, the symptoms described in the question are more indicative of hypoglycemia.
Choice C rationale
Cold stress can occur in newborns who are unable to maintain their body temperature within a normal range. While some of the symptoms described, such as mottled skin and acrocyanosis, can occur with cold stress, the presence of jitteriness and a weak cry are more indicative of hypoglycemia.
Choice D rationale
Respiratory Distress Syndrome (RDS) is a common problem in premature babies and is caused by a lack of surfactant in the lungs. While rapid, unlabored respirations can be a sign of RDS, the other symptoms described in the question, such as jitteriness and a weak cry, are not typically associated with RDS2.
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