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.

Position the client supine with knees flexed and place a small, rolled towel under one of their hips.

Palpate the fetal part positioned above the symphysis pubis.

Instruct the client to empty their bladder.

Palpate the fetal part positioned in the fundus.

Palpate the fetal parts along both sides of the uterus.

Answer and Explanation

The Correct Answer is C, A, D, E, B

The Leopold maneuvers are a common and systematic way to determine the position of a fetus inside the woman’s uterus. They are typically performed at prenatal examinations during the third trimester of pregnancy. Here is the correct sequence of actions a nurse should take: Instruct the client to empty their bladder. This is done to make the examination easier and more comfortable for the client ©. Position the client supine with knees flexed and place a small, rolled towel under one of their hips. This position helps relax the abdominal muscles and displaces the uterus to the side, reducing the risk of supine hypotensive syndrome (a). Palpate the fetal part positioned in the fundus. This helps determine the fetal lie and presentation (d). Palpate the fetal parts along both sides of the uterus. This helps identify the location of the fetal back and small parts (e). Palpate the fetal part positioned above the symphysis pubis. This helps determine the fetal attitude and degree of extension or flexion of the fetal head (b). Remember, these maneuvers should be performed gently and respectfully, with the nurse explaining each step to the client. The goal is to assess the position and presentation of the fetus, as well as estimate fetal weight, not to change the position of the fetus. If the nurse is unsure about the position or presentation of the fetus, an ultrasound may be needed for confirmation.

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Correct Answer is A

Explanation

Choice A rationale
An oxygen saturation of 89% in a newborn who was born 2 hours ago and was admitted to the neonatal intensive care unit with chest wall retractions and blue discoloration of the hands and feet indicates a decline in the newborn’s status. This level of oxygen saturation is below the normal range for a newborn, which is typically above 95%10111213. This could indicate that the newborn is not getting enough oxygen, which could be due to a variety of conditions, including respiratory distress syndrome.
Choice B rationale
Nasal flaring is a sign of respiratory distress in a newborn. However, it is a nonspecific sign and does not necessarily indicate a decline in the newborn’s status. It could be a normal response to the newborn’s efforts to breathe more effectively.
Choice C rationale
Fine crackles can be a sign of a lung condition in a newborn. However, they are a nonspecific sign and do not necessarily indicate a decline in the newborn’s status. They could be a normal finding in a newborn who was born 2 hours ago.
Choice D rationale
An apneic episode less than 15 seconds in a newborn who was born 2 hours ago is not necessarily indicative of a decline in the newborn’s status. Brief periods of apnea (pauses in breathing) are common in newborns and are usually not a cause for concern unless they last longer than 20 seconds or are associated with other signs of distress.

A. Preterm newborns might have a thick layer of brown fat that can cause them to quickly become overheated. B. Preterm newborns might shiver to warm up when they get too cool. C. Preterm newborns might sweat to cool off when they get too warm. D. Preterm newborns might have less muscle tone which exposes more body surfaces to heat loss.

Correct Answer is D

Explanation

Choice A rationale
Preterm newborns do not have a thick layer of brown fat. Brown fat is a type of fat that generates heat and is typically found in full-term newborns. It helps them maintain their body temperature. Preterm newborns have less brown fat, which makes them more susceptible to hypothermia.
Choice B rationale
Shivering is a mechanism used by the body to generate heat when it’s cold. However, preterm newborns cannot shiver. Their nervous systems are not fully developed, and they lack the muscle coordination necessary to shiver.
Choice C rationale
Sweating is another mechanism the body uses to regulate temperature. When the body is too warm, it produces sweat to cool down. However, preterm newborns do not sweat to cool off when they get too warm. Their sweat glands are not fully developed, and they may not be able to sweat effectively.
Choice D rationale
Preterm newborns have less muscle tone, which exposes more body surfaces to heat loss. Muscle tone provides insulation and generates heat. Because preterm newborns have less muscle mass, they have less insulation and generate less heat, making them more susceptible to hypothermia.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is evaluating a newborn who was born 2 hours ago and was admitted to the neonatal intensive care unit with chest wall retractions and blue discoloration of the hands and feet. Which finding indicates a decline in the newborn’s status?

Correct Answer is A

Explanation

A nurse is providing teaching to the guardians of a preterm newborn about temperature instability. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

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