Nokea
The nurse performs Leopold's maneuvers for a client admitted in labor. Which is the main goal of Leopold's maneuvers?
- A. To determine whether the client's cervix has dilated
- B. To assess the frequency and intensity of the contractions
- C. To assess whether membranes have been ruptured
- D. To determine the presentation and position of the fetus
Correct Answer: D
Rationale: The correct answer is D: To determine the presentation and position of the fetus. Leopold's maneuvers involve a series of palpations to assess the fetal lie, presentation, position, and engagement. By performing these maneuvers, the nurse can determine the position of the fetus in relation to the mother's pelvis and whether the baby is in a vertex or breech presentation. This information is crucial in planning for a safe delivery and identifying any potential complications.
Other choices are incorrect because:
A: Leopold's maneuvers do not directly assess cervical dilation.
B: Contractions are typically monitored separately using a tocodynamometer.
C: Checking for ruptured membranes is done through a separate assessment.
In summary, Leopold's maneuvers primarily focus on assessing the presentation and position of the fetus to guide the delivery process effectively.
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A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the following actions should the nurse take?
- A. Administer antiviral medication
- B. Schedule an ultrasound examination
- C. Administer Haemophilus influenza type b vaccine
- D. Schedule an indirect Coombs’ test
Correct Answer: B
Rationale: The correct answer is B: Schedule an ultrasound examination. Parvovirus B19 in pregnancy can lead to complications such as fetal hydrops. An ultrasound can monitor fetal well-being and detect any abnormalities. Administering antiviral medication (A) is not typically recommended for parvovirus B19. Administering the Haemophilus influenza type b vaccine (C) is unrelated to this condition. Performing an indirect Coombs' test (D) is used to detect maternal antibodies in Rh incompatibility, not related to parvovirus B19.
Two hours after delivery the nurse assesses the client and documents that the fundus is soft, boggy, above the level of the umbilicus, and displaced to the right side. The nurse encourages the client to void. Which is the rationale for this nursing action?
- A. A full bladder prevents normal contractions of the uterus.
- B. An overdistended bladder may press against the episiotomy causing dehiscence.
- C. Distention of the bladder can cause urinary stasis and infection.
- D. It makes the client more comfortable when the fundus is massaged.
Correct Answer: A
Rationale: The correct answer is A: A full bladder prevents normal contractions of the uterus. A full bladder can impede the involution process of the uterus by exerting pressure on it, inhibiting proper contraction. This can lead to postpartum hemorrhage and increased risk of retained placental fragments. Encouraging the client to void helps to relieve the pressure on the uterus, allowing it to contract effectively and aiding in the expulsion of lochia and prevention of complications.
Other choices are incorrect because:
B: An overdistended bladder may press against the episiotomy causing dehiscence - While this is a potential risk, it is not directly related to fundal assessment and contraction.
C: Distention of the bladder can cause urinary stasis and infection - While true, this is not the primary concern when assessing the fundus post-delivery.
D: It makes the client more comfortable when the fundus is massaged - Massaging the fundus is a separate intervention and does
A 35-week gestation infant was delivered by forceps. Which assessment findings should alert the nurse to a possible complication of the forceps delivery?
- A. Weak, ineffective suck, and scalp edema
- B. Molding of the head and jitteriness
- C. Shrill, high pitched cry, and tachypnea
- D. Hypothermia and hemoglobin of 12.5 g/dL
Correct Answer: A
Rationale: The correct answer is A: Weak, ineffective suck, and scalp edema. Forceps delivery can cause head trauma leading to facial nerve injury, resulting in weak suck and scalp edema. Molding of the head (choice B) is a normal finding after vaginal birth. Jitteriness (choice B) may be due to immaturity rather than a complication of forceps delivery. A shrill, high-pitched cry and tachypnea (choice C) are more indicative of respiratory distress, not specific to forceps delivery. Hypothermia and hemoglobin of 12.5 g/dL (choice D) are not directly related to complications of forceps delivery.
Which physiological change takes place during the puerperium?
- A. The endometrium begins to undergo alterations necessary for menstruation.
- B. The placenta begins to separate from the uterine wall.
- C. The uterus returns to a pre-pregnant size and location.
- D. The uterus contracts at regular intervals with dilation of the cervix occurring.
Correct Answer: C
Rationale: During the puerperium, the correct physiological change is that the uterus returns to a pre-pregnant size and location (Choice C). This is because after childbirth, the uterus undergoes involution, gradually decreasing in size back to its pre-pregnant state. This process involves the shedding of excess tissue and contraction of uterine muscles. The endometrium (Choice A) does not undergo alterations for menstruation until after the puerperium, as menstruation typically resumes around 6-8 weeks postpartum. The placenta (Choice B) should have been expelled completely during the third stage of labor, so it does not separate during the puerperium. The uterus does contract, but it is not at regular intervals with cervical dilation (Choice D) during the puerperium.
A nurse is planning discharge for a client who is 3 days postpartum. Which of the following non pharmacological interventions should the nurse include in the plan of care for lactation suppression?
- A. Place warm, moist packs on the breast.
- B. Apply cabbage leaves to the breast.
- C. Wear a loose-fitting bra.
- D. Put green tea bags on the breasts.
Correct Answer: B
Rationale: The correct answer is B: Apply cabbage leaves to the breast. Cabbage leaves have been shown to help with lactation suppression due to their anti-inflammatory properties. Placing cabbage leaves on the breasts can help reduce milk supply by decreasing blood flow to the area. This method is safe, inexpensive, and easily accessible.
Choice A (Place warm, moist packs on the breast) is incorrect as warmth can actually stimulate milk production. Choice C (Wear a loose-fitting bra) is also incorrect as it does not directly address lactation suppression. Choice D (Put green tea bags on the breasts) is not effective for lactation suppression and may not be safe for the newborn if ingested.