Nokea
A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
- A. Identify the attitude of the head.
- B. Palpate the fundus to identify the fetal part.
- C. Determine the location of the fetal back.
- D. Palpate for the fetal part presenting at the inlet.
Correct Answer: B, C, D, A
Rationale: The correct order for performing Leopold maneuvers is B, C, D, A. Firstly, palpating the fundus (B) helps determine the fetal part. Next, determining the location of the fetal back (C) guides the nurse to find the fetal back. Palpating for the fetal part at the inlet (D) helps identify its presentation. Lastly, identifying the attitude of the head (A) completes the assessment. Other choices are not relevant to the sequential assessment in Leopold maneuvers.
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A nurse is caring for a client who is at 10 weeks of gestation. Which of the following findings should the nurse report to the provider?
- A. Frequent vomiting with weight loss of 3 lb in 1 week.
- B. Reports of mood swings.
- C. Nosebleeds occurring approximately 3 times per week.
- D. Increased vaginal discharge.
Correct Answer: A
Rationale: The correct answer is A. Frequent vomiting with weight loss of 3 lb in 1 week can indicate hyperemesis gravidarum, a severe form of nausea and vomiting during pregnancy that can lead to dehydration and electrolyte imbalances. This finding is concerning and requires immediate medical attention to prevent complications. Reporting this to the provider allows for timely intervention.
Other choices are incorrect:
B: Reports of mood swings are common during pregnancy due to hormonal changes and are not typically a cause for immediate concern.
C: Nosebleeds occurring approximately 3 times per week can be due to increased blood flow during pregnancy and are usually not a significant concern unless severe or persistent.
D: Increased vaginal discharge is a common symptom in early pregnancy due to hormonal changes and increased blood flow to the pelvic area. It is not typically an urgent issue unless accompanied by other symptoms like itching or foul odor.
A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?
- A. Acrocyanosis.
- B. Transient strabismus.
- C. Jaundice.
- D. Caput succedaneum.
Correct Answer: C
Rationale: The correct answer is C: Jaundice. Jaundice in a newborn within the first 24 hours can indicate pathological conditions like hemolytic disease or liver dysfunction, requiring immediate attention. Acrocyanosis (A) and caput succedaneum (D) are common benign conditions in newborns. Transient strabismus (B) is a temporary eye misalignment that often resolves on its own. Other choices are not provided.
Which of the following findings should the nurse report to the provider? Select all that apply
- A. Abdominal assessment.
- B. Vaginal Discharge.
- C. Heart rate.
- D. Temperature.
- E. Dyspareunia.
- F. Condom usage.
Correct Answer: B, E
Rationale:
The nurse should report vaginal discharge (B) as it could indicate infection or other issues. Dyspareunia (E) should also be reported as it can indicate underlying problems. Abdominal assessment (A) may be part of routine care but doesn't necessarily require immediate reporting. Heart rate (C) and temperature (D) are vital signs that should be monitored but don't specifically indicate a need for immediate reporting. Condom usage (F) is important for sexual health discussions but does not require reporting to the provider.
A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect?
- A. Deep tendon reflexes 4+.
- B. Fundal height 14 cm.
- C. Blood pressure 142/94 mm Hg.
- D. FHR 152/min.
Correct Answer: D
Rationale: The correct answer is D: FHR 152/min. At 18 weeks gestation, the fetal heart rate (FHR) should be around 140-160 bpm, making a rate of 152/min within the expected range. This indicates normal fetal cardiac activity and development.
A: Deep tendon reflexes are not typically assessed during routine prenatal visits and are not related to gestational age.
B: Fundal height at 18 weeks should be around the level of the umbilicus, which is closer to 20 cm, not 14 cm.
C: Blood pressure of 142/94 mm Hg is elevated and indicates hypertension, which is not expected at 18 weeks gestation.
E, F, G: No other options provided.
A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?
- A. Administer penicillin G 2.4 million units IM to the client.
- B. Instruct the client to schedule annual pelvic examination.
- C. Tell the client they will start medication for HIV immediately after delivery.
- D. Report the client's condition to the local health Department.
Correct Answer: D
Rationale: The correct answer is D: Report the client's condition to the local health department. This is important to ensure proper monitoring, follow-up, and infection control measures. Reporting is necessary for contact tracing, prevention of transmission, and accessing appropriate support services. Administering penicillin G (A) is not indicated for HIV; the client needs antiretroviral therapy. Scheduling annual pelvic exams (B) is important for general health but not specific to HIV care. Waiting until after delivery to start HIV medication (C) is not recommended as timely treatment is crucial.