Nokea
When performing Leopold's maneuvers on a primigravid client, the nurse is palpating the uterus as shown below. Which of the following maneuvers is the nurse performing?
- A. First maneuver.
- B. Second maneuver.
- C. Third maneuver.
- D. Fourth maneuver.
Correct Answer: C
Rationale: The third Leopold's maneuver involves palpating the suprapubic area to determine the presenting part and its engagement, typically performed as described in the context. The first identifies the fundal contents, the second locates the fetal back, and the fourth assesses cephalic prominence.
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While caring for a primipara diagnosed with deep vein thrombosis at 48 hours postpartum who is receiving treatment with bed rest and intravenous heparin therapy, the nurse should contact the client's physician immediately if the client exhibited which of the following?
- A. Pain in her calf.
- B. Dyspnea.
- C. Hypertension.
- D. Bradycardia.
Correct Answer: B
Rationale: Dyspnea may indicate a pulmonary embolism, a life-threatening complication requiring immediate attention.
A 24-year-old primigravid client in active labor requests use of the jet hydrotherapy tub to aid in pain relief. The nurse bases the response on the understanding that this therapy is commonly contraindicated for clients with which of the following?
- A. A required membranes.
- B. Multifetal gestation.
- C. Diabetes mellitus.
- D. Hypotonic labor patterns.
Correct Answer: A
Rationale: Jet hydrotherapy (e.g., whirlpool tubs) is contraindicated with ruptured membranes due to the risk of infection from water entering the vaginal canal. Multifetal gestation, diabetes, and hypotonic labor are not absolute contraindications unless other complications are present.
A primigravid client at 37 weeks' gestation with gestational diabetes is in active labor at 5 cm dilation. The nurse notes a blood glucose level of 45 mg/dL. What is the nurse's first action?
- A. Administer 50% dextrose IV push.
- B. Offer the client a high-carbohydrate snack.
- C. Recheck the blood glucose level.
- D. Notify the physician of the result.
Correct Answer: B
Rationale: A blood glucose of 45 mg/dL indicates maternal hypoglycemia, common in gestational diabetes due to insulin use. Offering a high-carbohydrate snack is the first action to stabilize glucose safely. Dextrose is for severe cases, rechecking delays treatment, and notification follows initial management.
The physician orders ampicillin The dose is 100 mg/kg per dose for a newly admitted neonate. The neonate weighs 1,350 grams. How many milligrams should the nurse administer?
- A. mg.
Correct Answer: B
Rationale: The neonate weighs 1,350 g (1.35 kg). The dose is 100 mg/kg, so 100 mg/kg × 1.35 kg = 135 mg. The nurse should administer 135 mg.
Which of the following indicates successful latch-on during a breast-feeding session?
- A. Neonate's lips are flanged outward.
- B. Mother reports sharp pain throughout feeding.
- C. Neonate's cheeks are dimpled.
- D. Mother hears clicking sounds during sucking.
Correct Answer: A
Rationale: Flanged lips indicate a proper latch, ensuring effective milk transfer and preventing nipple trauma.