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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: The correct sequence for performing Leopold maneuvers is A, B, C, D. Firstly, instructing the client to empty their bladder (A) allows for better visualization and palpation of the fetus. Positioning the client supine with knees flexed and a rolled towel under one hip (B) helps relax the abdomen and facilitate palpation. Palpating the fetal part in the fundus (C) helps determine the fetal presentation and position. Finally, palpating the fetal parts along both sides of the uterus (D) aids in assessing the fetal lie and engagement. Choices E, F, and G are not relevant to the correct sequence of Leopold maneuvers.
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A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception. Which of the following instructions should the nurse include?
- A. You should have your provider refit you for a new diaphragm.'
- B. You should use an oil-based vaginal lubricant when inserting your diaphragm.'
- C. You should keep the diaphragm in place for at least 4 hours after intercourse.'
- D. You should store your diaphragm in sterile water after each use.'
Correct Answer: A
Rationale: The correct answer is A: "You should have your provider refit you for a new diaphragm." This is important because postpartum changes in the body can affect the fit of the diaphragm. A refitting ensures proper size and fit for effective contraception. Choice B is incorrect because oil-based lubricants can damage latex diaphragms. Choice C is incorrect as the diaphragm should be kept in place for at least 6-8 hours, not 4 hours, for effective contraception. Choice D is incorrect as diaphragms should be stored dry, not in sterile water, to prevent damage.
A nurse in a provider’s office is caring for a 20-year-old client who is at 12 weeks of gestation and requests an amniocentesis to determine the sex of the fetus. Which of the following responses should the nurse make?
- A. You cannot have an amniocentesis until you are at least 35 years of age.
- B. This procedure determines if your baby has genetic or congenital disorders.
- C. Your provider will schedule a chorionic villus sampling to determine the sex of your baby.
- D. We can schedule the procedure for later today if you’d like.
Correct Answer: B
Rationale: The correct answer is B: This procedure determines if your baby has genetic or congenital disorders. At 12 weeks of gestation, amniocentesis is typically not done to determine the sex of the fetus but rather to identify genetic abnormalities or congenital disorders. Providing this information allows the client to make informed decisions about their pregnancy and potential interventions.
A: You cannot have an amniocentesis until you are at least 35 years of age - This statement is incorrect as age alone is not the sole criteria for recommending amniocentesis.
C: Your provider will schedule a chorionic villus sampling to determine the sex of your baby - Chorionic villus sampling is also not typically done to determine the sex of the fetus.
D: We can schedule the procedure for later today if you’d like - This is incorrect as scheduling an amniocentesis without a medical indication is not appropriate.
A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan?
- A. Feed the newborn 1 oz of water every 4 hr.
- B. Apply lotion to the newborn’s skin three times per day.
- C. Remove all clothing from the newborn except the diaper.
- D. Discontinue therapy if the newborn develops a rash.
Correct Answer: C
Rationale: The correct answer is C: Remove all clothing from the newborn except the diaper. This is important during phototherapy as it maximizes the skin exposure to the light, aiding in the breakdown of bilirubin. Removing clothing allows for better absorption of the therapeutic light.
A is incorrect as water should not be given to a newborn without a specific medical indication. B is unnecessary and may interfere with the effectiveness of the phototherapy. D is incorrect as a rash is a common side effect of phototherapy and does not necessarily warrant discontinuation of treatment.
A nurse is collecting data from a client who is at 30 weeks of gestation. Which of the following findings should the nurse identify as a manifestation of pyelonephritis?
- A. Epigastric discomfort
- B. Flank pain
- C. Temperature 37.7°C (99.8°F)
- D. Abdominal cramping
Correct Answer: B
Rationale: The correct answer is B: Flank pain. Pyelonephritis is an infection of the kidneys commonly characterized by flank pain. At 30 weeks of gestation, the uterus enlarges and can lead to obstruction of the ureters, increasing the risk of urinary stasis and infection. Epigastric discomfort (choice A) is more indicative of issues like preeclampsia. Temperature elevation (choice C) can be a sign of infection but is not specific to pyelonephritis. Abdominal cramping (choice D) is more likely related to uterine contractions or gastrointestinal issues.
A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?
- A. Single palmar creases (p200
- B. Down Syndrome)
- C. Rust-stained urine
- D. Transient circumoral cyanosis
- E. Subconjunctival hemorrhage
Correct Answer: A
Rationale: The correct answer is A: Single palmar creases. This finding is associated with Down Syndrome, which requires further evaluation by the provider. Single palmar creases are a physical characteristic commonly seen in infants with Down Syndrome. Reporting this to the provider allows for early intervention and appropriate management. Choices B, C, D, and E are incorrect because Down Syndrome (choice B) is not a clinical finding to report but rather a condition associated with single palmar creases. Rust-stained urine (choice C) may indicate hematuria but is not a common concern in newborns. Transient circumoral cyanosis (choice D) is a common finding in newborns that usually resolves on its own. Subconjunctival hemorrhage (choice E) is also a common and benign finding in newborns.