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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The nurse should provide the instruction to “verify the identity of anyone who wants to remove your baby from the room” in the teaching about security procedures. It is important for parents to be vigilant and ensure that only authorized personnel have access to their baby.
Correct Answer is B
Explanation
Choice A rationale
Limiting the length of breastfeeding to 5 minutes per breast is not typically recommended. It’s important for the baby to empty each breast completely, as the fat content of the milk increases as the breast empties.
Choice B rationale
Assessing the newborn’s latch while breastfeeding is crucial. A poor latch can cause sore nipples. The baby should take as much of the areola into their mouth as possible, with more areola showing at the top lip than the bottom.
Choice C rationale
Waiting 4 hours between daytime feedings is not typically recommended for a breastfeeding newborn. Newborns typically need to feed every 2-3 hours, or 8-12 times in 24 hours.
Choice D rationale
Offering supplemental formula between the newborn’s feedings can interfere with establishing a good milk supply and should be avoided unless medically necessary.
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