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 identify the fetal part. Next, determining the location of the fetal back (C) gives insight into the baby's position. Palpating for the fetal part at the inlet (D) helps determine the presenting part. Finally, identifying the attitude of the head (A) concludes the assessment. The other choices do not align with the sequential nature of Leopold maneuvers, making them incorrect.
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A nurse is providing teaching to the parents of a newborn about newborn genetic screening. Which of the following statements should the nurse Include in the teaching?
- A. This test will be repeated when your baby is 2 months old.
- B. A nurse will draw blood from your baby's inner elbow.
- C. This test should be performed after your baby is 24 hours old.
- D. Your baby will be given 2 ounces of water to drink prior to the test.
Correct Answer: C
Rationale: Rationale: The correct answer is C because newborn genetic screening should be performed after the baby is 24 hours old to ensure accurate results. Testing too early may lead to false negatives. Choice A is incorrect because the test is typically done once soon after birth. Choice B is incorrect as blood is usually drawn from the baby's heel, not inner elbow. Choice D is incorrect as newborns should not be given water before the test due to risk of aspiration.
A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect?
- A. Decreased platelet count.
- B. Increased erythrocyte sedimentation rate (ESR).
- C. Decreased megakaryocytes.
- D. Increased WBC.
Correct Answer: A
Rationale: The correct answer is A: Decreased platelet count. In idiopathic thrombocytopenia purpura (ITP), there is a decrease in platelet count due to immune-mediated destruction of platelets. This can lead to an increased risk of bleeding.
Explanation for other choices:
B: Increased erythrocyte sedimentation rate (ESR) is not typically associated with ITP.
C: Decreased megakaryocytes may be seen in some cases of ITP but is not a consistent finding.
D: Increased WBC is not a characteristic finding in ITP.
Therefore, the most relevant finding in a client with ITP would be a decreased platelet count due to the underlying pathophysiology of the condition.
A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client?
- A. Percutaneous umbilical blood sampling.
- B. Amnioinfusion.
- C. Biophysical profile (BPP).
- D. Chorionic villus sampling (CVS).
Correct Answer: C
Rationale: The correct answer is C: Biophysical profile (BPP). At 41 weeks gestation with a positive contraction stress test, the client may be at risk for uteroplacental insufficiency. A BPP assesses fetal well-being by evaluating fetal movement, tone, breathing, amniotic fluid volume, and fetal heart rate reactivity. This test helps determine if the fetus is getting enough oxygen and nutrients. Preparing the client for a BPP is crucial in monitoring the fetal status and making decisions regarding further management.
Incorrect choices:
A: Percutaneous umbilical blood sampling is an invasive procedure used to evaluate fetal blood gases and acid-base status, typically performed when there are concerns about fetal well-being like severe growth restriction or Rh incompatibility.
B: Amnioinfusion is the infusion of fluid into the amniotic cavity and is used to correct oligohydramnios (low amniotic fluid volume).
D: Chorionic villus
A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?
- A. O2 saturation.
- B. Temperature.
- C. Blood pressure.
- D. Urinary output.
Correct Answer: B
Rationale: The correct answer is B: Temperature. During an amniotomy, there is a risk of infection due to the introduction of bacteria into the amniotic sac. Monitoring the client's temperature is crucial as fever can indicate infection, which can be life-threatening for both the client and the fetus. It is essential to detect early signs of infection to initiate prompt treatment. Assessing O2 saturation, blood pressure, and urinary output are important but not the priority in this situation. O2 saturation may be monitored if there are concerns about fetal distress, blood pressure for signs of preeclampsia, and urinary output for kidney function, but these are not immediate concerns post-amniotomy.
A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take?
- A. Restrict hourly fluid intake to 150 mL/hr.
- B. Have calcium gluconate readily available.
- C. Assess deep tendon reflexes every 6 hr.
- D. Monitor intake and output every 4 hr.
Correct Answer: B
Rationale: The correct answer is B: Have calcium gluconate readily available. Magnesium sulfate can lead to magnesium toxicity, causing respiratory depression and cardiac arrest. Calcium gluconate is the antidote for magnesium toxicity, so having it readily available is crucial for immediate administration if toxicity occurs. Option A is incorrect as fluid intake should not be restricted in preeclampsia. Option C is incorrect as deep tendon reflexes should be assessed more frequently (every 1-2 hours) due to the risk of hypermagnesemia. Option D is incorrect as intake and output should be monitored hourly to detect any changes in renal function.