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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 is performed to: Identify the fetal part that is lying just above the inlet of the true pelvis (i.e., what part is presenting). It helps determine if the presenting part (usually the head or buttocks) is engaged, floating, or movable.
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A primigravid client in active labor has had no anesthesia. The client's cervix is 7 cm dilated, and she is starting to feel considerable discomfort during the first 10 cm to the client's sacral client is a left side-lying position. The nurse should encourage which of the following?
- A. Rapid, shallow chest breathing.
- B. Deep chest breathing.
- C. Rapid pant-blow breathing.
- D. Slow abdominal breathing.
Correct Answer: D
Rationale: Slow abdominal breathing promotes relaxation and oxygenation, helping manage discomfort in active labor without anesthesia. Rapid or shallow breathing may lead to hyperventilation, and deep chest breathing is less effective for pain control.
A multigravid client thought to be at 14 weeks' gestation reports that she is experiencing such severe morning sickness that "she has not been able to keep anything down for a week." The nurse should assess for signs and symptoms of which of the following?
- A. Hypercalcemia.
- B. Hypobilirubinemia.
- C. Hypokalemia.
- D. Hyperglycemia.
Correct Answer: C
Rationale: Persistent vomiting can lead to hypokalemia.
Which of the following would the nurse include in the primiparous client's discharge teaching plan about measures to provide visual stimulation for the neonate?
- A. Maintain eye contact while talking to the baby.
- B. Paint the baby's room in bright colors accented with teddy bears.
- C. Use brightly colored animals and cartoon figures on the wall.
- D. Move a brightly colored rattle in front of the baby's eyes.
Correct Answer: A
Rationale: Maintaining eye contact promotes visual stimulation and bonding, suitable for a neonate's developmental stage.
A primigravid client with insulin-dependent diabetes tells the nurse that the contraction stress test performed earlier in the day was suspicious. The nurse interprets this test result as indicating that the fetal heart rate pattern showed which of the following?
- A. Frequent late decelerations.
- B. Decreased fetal movement.
- C. Inconsistent late decelerations.
- D. Lack of fetal movement.
Correct Answer: C
Rationale: Suspicious results indicate inconsistent late decelerations.
While assessing the fundus of a multiparous client 36 hours after delivery of a term neonate, the nurse notes a separation of the abdominal muscles. What action should the nurse take based on this assessment?
- A. Notify the health care provider of the separation.
- B. Discuss with the client that no further action is needed.
- C. Demonstrate exercises involving head and shoulder lifting.
- D. Refer the client to a surgeon for surgical repair after 6 weeks postpartum.
Correct Answer: C
Rationale: Diastasis recti is managed with specific exercises like head and shoulder lifts to strengthen abdominal muscles.