A nurse is planning to assist with Leopold maneuvers on a client who is at 37 weeks of gestation. Which of the following actions should the nurse plan to take?
Ask the client to empty their bladder.
Assist the client into a left-lateral position.
Apply an external fetal monitor to the clients abdomen.
Instruct the client to perform nipple stimulation.
Able to move from back to front.
Correct Answer : A,B,C
Choice A reason: The nurse should plan to ask the client to empty their bladder before performing Leopold maneuvers. The rationale behind this is to ensure that the client's bladder is empty to allow for better palpation of the uterus and fetal position. A full bladder can interfere with accurate assessment and may lead to incorrect findings during the examination.
Choice B reason:
The nurse should assist the client into a left-lateral position. This position is ideal for performing Leopold maneuvers because it helps to displace the uterus away from the vena cava, reducing the risk of supine hypotension syndrome. Moreover, the left-lateral position promotes optimal blood flow to the placenta, which is essential for the well-being of the fetus during the examination.
Choice C reason:
The nurse should apply an external fetal monitor to the client's abdomen after completing the Leopold maneuvers. The purpose of Leopold maneuvers is to determine the fetal position and presentation manually. Once this information is obtained, applying the external fetal monitor allows continuous monitoring of the fetal heart rate and uterine contractions to assess the baby's well-being and the progression of labor.
Choice D reason:
The nurse should not instruct the client to perform nipple stimulation when planning to assist with Leopold maneuvers. Nipple stimulation is a method to induce or augment labor, and it is not related to the process of assessing fetal position and presentation using Leopold maneuvers. It may lead to unnecessary contractions and confusion during the examination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
The nurse should not tell the client to lie flat on their back for the duration of the nonstress test. It is essential for pregnant clients to be in a semi-reclining or left lateral position during the test to avoid supine hypotension syndrome. This condition can occur when the weight of the uterus compresses the inferior vena cava, reducing blood flow to the heart and potentially compromising the baby's well-being.
Choice B reason:
The nurse should not instruct the client to lightly brush their palms across their nipples during the test. This statement is not related to the nonstress test procedure. The nonstress test involves monitoring the baby's heart rate in response to its movements, and nipple stimulation is not a standard part of the test.
Choice C reason:
The nurse should not advise the client not to eat or drink anything for 4 hours before the test. It is important for pregnant clients to have adequate nutrition and hydration, especially during the third trimester. Restricting food and drink for such a prolonged period could lead to dehydration and may not be necessary for the test.
Choice D reason:
This is the correct choice. During a nonstress test, the client is connected to a fetal heart rate monitor. They are asked to press a button whenever they feel the baby moving. This allows the healthcare provider to correlate the baby's movements with changes in the heart rate pattern, which helps assess the baby's well-being.
Correct Answer is A
Explanation
"I should start trying to breastfeed within an hour of having my baby.” Choice A reason:
The client's statement indicates an understanding of the teaching because initiating breastfeeding within the first hour after birth is crucial for successful breastfeeding. This early initiation allows the baby to receive colostrum, which is rich in nutrients and antibodies, supporting the baby's immune system and providing essential nutrition during the initial stages of life. Additionally, early breastfeeding helps establish a strong bond between the mother and the baby while promoting the baby's suckling reflex.
Choice B reason:
The statement in Choice B is incorrect. Formula feeding between breastfeedings is not recommended in the early stages of breastfeeding, especially if the baby loses 5 percent of their birth weight. Newborns often lose some weight initially, which is normal, and it can be regained through effective breastfeeding. Supplementing with formula may interfere with establishing a good milk supply and the baby's ability to latch properly.
Choice C reason:
This statement in Choice C is incorrect. During breastfeeding sessions, it's essential for the baby to nurse on one breast fully before switching to the other breast. Allowing the baby to nurse for at least 10-15 minutes on each breast ensures they receive the hindmilk, which is higher in fat and essential for the baby's growth and development.
Choice D reason:
The statement in Choice D is incorrect. Offering a pacifier right after breastfeeding might interfere with the baby's feeding cues and lead to decreased breastfeeding frequency.
Newborns may suck for non-nutritive reasons, and offering a pacifier too soon can hinder proper breastfeeding establishment, as they may satisfy their sucking needs with the pacifier rather than nursing at the breast.
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