Nokea
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.
- A. Instruct the client to empty their bladder.
- B. Position the client supine with knees flexed and place a small, rolled towel under one of their hips.
- C. Palpate the fetal part positioned in the fundus.
- D. Palpate the fetal parts along both sides of the uterus.
Correct Answer: A, B, C, D
Rationale: Action to Take: A, B; Potential Condition: C; Parameter to Monitor: D, E.
The correct sequence of actions for performing Leopold maneuvers includes:
A) Instruct the client to empty their bladder to enhance visualization and palpation accuracy.
B) Position the client supine with knees flexed to provide access and comfort for the client during the procedure.
C) Palpate the fetal part positioned in the fundus to determine the baby's presentation and position.
D) Palpate the fetal parts along both sides of the uterus to assess the location and movement of the fetus.
It is important to follow these steps to accurately assess the fetal position and presentation. Other choices are incorrect as they do not align with the standard procedure for Leopold maneuvers.
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A nurse is providing discharge teaching to a client following tubal ligation. Which of the following statements by the client indicates an understanding of the teaching?
- A. Premenstrual tension will no longer be present.
- B. My monthly menstrual period will be shorter.
- C. Hormone replacements will be needed following this procedure.
- D. Ovulation will remain the same.
Correct Answer: D
Rationale: The correct answer is D: Ovulation will remain the same. This statement indicates an understanding of the teaching because tubal ligation does not affect ovulation; it only blocks the fallopian tubes to prevent the egg from traveling to the uterus. The client should still ovulate as before, but pregnancy is prevented by blocking the egg's path.
Incorrect choices:
A: Premenstrual tension will no longer be present - This is incorrect because tubal ligation does not affect premenstrual tension.
B: My monthly menstrual period will be shorter - This is incorrect as tubal ligation does not affect the length of menstrual periods.
C: Hormone replacements will be needed following this procedure - This is incorrect as tubal ligation does not typically require hormone replacements.
A nurse is assisting the provider to administer a dinoprostone insert to induce labor for a client. Which of the following actions should the nurse take?
- A. Allow the medication to reach room temperature prior to administration.
- B. Place the client in a semi-Fowler’s position for 1 hr after administration.
- C. Instruct the client to avoid urinary elimination until after administration.
- D. Verify that informed consent is obtained prior to administration.
Correct Answer: D
Rationale: The correct answer is D: Verify that informed consent is obtained prior to administration. This step is crucial to ensure the client understands the risks and benefits of the procedure. It promotes client autonomy and helps prevent legal issues.
A: Allowing the medication to reach room temperature is not a necessary step for administering dinoprostone insert.
B: Placing the client in a semi-Fowler's position is not indicated after administering dinoprostone insert.
C: Instructing the client to avoid urinary elimination is not necessary and could be harmful to the client.
E, F, G: No other options are provided, but they would likely be incorrect as well.
A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. Which of the following clinical findings should the nurse expect?
- A. Telangiectatic nevi
- B. Facial petechiae
- C. Periauricular papillomas
- D. Erythema toxicum
Correct Answer: B
Rationale: The correct answer is B: Facial petechiae. When a newborn is born with a nuchal cord (umbilical cord wrapped around the neck), compression can occur, leading to facial petechiae. This occurs due to the increased pressure on the blood vessels in the face during delivery. Telangiectatic nevi (A) are unrelated to nuchal cord. Periauricular papillomas (C) are benign skin lesions often found in newborns but are not specific to nuchal cord. Erythema toxicum (D) is a common benign rash in newborns, but it is not directly associated with a nuchal cord.
A nurse is caring for a client who reports spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and notices that the umbilical cord is protruding. After calling for assistance and notifying the provider, which of the following actions should the nurse take next?
- A. Perform a vaginal examination by applying upward pressure on the presenting part.
- B. Cover the umbilical cord with a sterile saline-saturated towel.
- C. Administer oxygen via nonrebreather mask at 8 L/min.
- D. Initiate an infusion of IV fluids for the client.
Correct Answer: B
Rationale: Correct Answer: B - Cover the umbilical cord with a sterile saline-saturated towel.
Rationale: Protruding umbilical cord is a medical emergency that can lead to cord compression and compromise blood flow to the baby, resulting in fetal distress. Covering the cord with a sterile saline-saturated towel helps to prevent cord compression and maintain blood flow until delivery can be expedited. This action ensures the baby continues to receive oxygen and nutrients.
Summary of Incorrect Choices:
A: Performing a vaginal examination could further compress the cord and worsen the situation.
C: Administering oxygen may be beneficial for the mother but does not address the immediate risk to the baby from cord compression.
D: Initiating an IV infusion is important but does not address the urgent need to protect the umbilical cord.
E, F, G: No information provided.
A nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery and reports constipation. Which of the following findings should the nurse identify as a contraindication to the use of a suppository?
- A. Vaginal candidiasis
- B. Abdominal distention
- C. Afterpains
- D. Third-degree perineal laceration
Correct Answer: D
Rationale: The correct answer is D: Third-degree perineal laceration. Using a suppository in a client with a third-degree perineal laceration can lead to further trauma and delayed wound healing. Suppositories are contraindicated in such cases to prevent infection and promote proper healing.
A: Vaginal candidiasis is not a contraindication for using a suppository, as it can actually help in treating the infection.
B: Abdominal distention would not necessarily contraindicate the use of a suppository.
C: Afterpains are common postpartum and do not specifically contraindicate the use of a suppository.
E, F, G: No other options provided.