Nokea
A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow.
- A. Palpate the fundus to identify the fetal part.
- B. Determine the location of the fetal back.
- C. Palpate for the fetal part presenting at the inlet.
- D. Identify the attitude of the head.
Correct Answer: A,B,CD
Rationale: The correct sequence for performing Leopold maneuvers is A, B, C, and D. Firstly, palpating the fundus to identify the fetal part helps determine the position of the baby in the uterus. Secondly, determining the location of the fetal back provides information on the baby's position relative to the mother's spine. Thirdly, palpating for the fetal part presenting at the inlet helps identify which part of the baby is entering the birth canal. Lastly, identifying the attitude of the head gives insight into how the baby is positioned within the pelvis for delivery. This sequential approach allows for a systematic assessment of fetal position and presentation. The other choices are incorrect as they do not follow the correct order of Leopold maneuvers, which can lead to inaccurate assessment and potential complications during labor and delivery.
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A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client’s history should the nurse recognize as a contraindication to oral contraceptives? (Select all that apply.)
- A. Cholecystitis
- B. Hypertension
- C. Human papillomavirus
- D. Migraine headaches
Correct Answer: A, B, D
Rationale: The correct answer is A, B, D. Cholecystitis is a contraindication due to increased risk of gallbladder disease with oral contraceptives. Hypertension is a contraindication because estrogen in oral contraceptives can worsen hypertension. Migraine headaches with aura are a contraindication due to increased risk of stroke. Human papillomavirus is not a contraindication unless it is accompanied by other conditions.
A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain?
- A. Decreased heart rate
- B. Chin quivering
- C. Pinpoint pupils
- D. Slowed respirations
Correct Answer: B
Rationale: The correct answer is B: Chin quivering. Chin quivering is a common sign of pain in newborns. It indicates discomfort and distress. Decreased heart rate (choice A), pinpoint pupils (choice C), and slowed respirations (choice D) are not typical signs of pain in newborns. Decreased heart rate may indicate relaxation, pinpoint pupils may suggest neurological issues, and slowed respirations may be a response to other factors. Therefore, the most appropriate finding indicating pain in this scenario is chin quivering.
A nurse is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?
- A. Check the client's temperature.
- B. Observe for uterine contractions.
- C. Administer Rho(D) immune globulin.
- D. Monitor the FHR.
Correct Answer: C
Rationale: The correct answer is C: Administer Rho(D) immune globulin. This is the priority intervention following an amniocentesis in an Rh-negative client at 15 weeks gestation to prevent Rh isoimmunization. Administering Rho(D) immune globulin helps prevent the mother's immune system from forming antibodies against Rh-positive fetal blood cells, which could lead to hemolytic disease in the newborn. Checking the client's temperature (A) is not the priority as there is no immediate risk related to the procedure. Observing for uterine contractions (B) is important but not the priority immediately post-procedure. Monitoring the FHR (D) is important but not the priority at this time.
A nurse is preparing to administer an IM injection to a newborn. Which of the following sites should the nurse select?
- A. Vastus lateralis
- B. Dorsogluteal
- C. Deltoid
- D. Rectus femoris
Correct Answer: A
Rationale: The correct answer is A: Vastus lateralis. For newborns, the vastus lateralis muscle is the preferred site for intramuscular injections due to its large muscle mass, minimal nerves and blood vessels, and reduced risk of hitting bone. It is located on the lateral aspect of the thigh and is easily accessible for injections. This site also allows for proper absorption of the medication. The other options are not ideal for newborns: B: Dorsogluteal is not recommended due to the risk of damaging the sciatic nerve, C: Deltoid is typically used for older children and adults, and D: Rectus femoris is not a common site for IM injections in newborns.
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 an 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 crucial to ensure proper monitoring, contact tracing, and prevention of transmission to others. Reporting the client's HIV status is mandatory for public health purposes. Administering penicillin G (choice A) is not relevant in this scenario. Instructing the client to schedule a pelvic exam (choice B) and starting HIV medication after delivery (choice C) are not immediate actions needed to address the client's HIV status.