Leopold Maneuvers & Fundal height
A nurse is preparing to perform Leopold maneuvers on a pregnant client at 38 weeks’ gestation. Which action should the nurse take first?
A. Ask the client to empty her bladder
B. Palpate the lower portion of the uterus to identify fetal engagement
C. Palpate the fundus to identify the fetal part present
D. Assess the fetal heart rate
What is ask the client to empty her bladder?
Which finding collected during the prenatal interview indicates a high-risk pregnancy?
A. First pregnancy
B. Age 27
C. Chronic hypertension
D. Has not received the influenza vaccine
What is Chronic hypertension?
A nurse is performing intermittent auscultation of a term laboring client. The fetal heart rate (FHR) is 140 bpm with moderate variability and accelerations present. What should the nurse do?
What is Document findings and continue routine monitoring ?
A client is in active labor (6 cm dilated). Which nursing intervention is appropriate during this stage?
A. Encourage the client to begin pushing
B. Monitor vital signs and fetal heart rate every 30 minutes
C. Assist with ambulation and position changes
D. Prepare for immediate delivery
What is Assist with ambulation and position changes
A newborn’s APGAR score at 1 minute is:
Heart rate: 110 bpm
Respiratory effort: slow, weak cry
Muscle tone: some flexion
Reflex irritability: grimace
Color: pink body, blue extremities
What is the APGAR score?
What is 8?
When the nurse performs the third Leopold maneuver, what is the purpose? .
What is determine the descent and engagement of the fetus ?
What 5 things should be included in a prenatal interview checklist?
What is:
Demographic information
Obstetric History (GTPAL)
LMP (last menstrual period) – first day, Cycle regularity, Contraceptive use
Current Pregnancy Symptoms
Medical & Surgical History
Infection & Immunization Screening
Lifestyle Assessment
Substance Use Screening
Cultural & Spiritual Considerations
Genetic/Family History
Which pattern is most consistent with umbilical cord compression?
A. Early decelerations
B. Variable decelerations
C. Late decelerations
D. Sinusoidal pattern
What is Variable decelerations
Exercises that can assist the woman in regaining muscle tone after birth.
What are Kegel exercises?
The newborn is crying weakly with HR 95 bpm. First action:
A. Dry, stimulate, and provide warmth
B. Apply identification bands
C. Give first feeding
D. Take APGAR at 5 min only
.
What is Dry, stimulate, and provide warmth ?
Which describes the correct technique to measure fundal height?
A. Measure from the umbilicus to the top of the fundus
B. Measure from the symphysis pubis to the top of the fundus
C. Measure on the patient’s left side only
D. Measure from the fundus down to the pubic bone, using inches
What is Measure from the symphysis pubis to the top of the fundus ?
Mention 3 Patient Education Needs for a pregnant woman
What is:
Prenatal schedule
Warning signs
Nutrition/weight gain goals
Folic acid and prenatal vitamins
Testing (ultrasound, labs, screenings)
A nurse is preparing to apply external fetal monitoring. The client asks, “Where will you put the monitors?”
Which is the best nursing response?
A. “One goes over your fundus to monitor contractions, and one over the fetal back to monitor the baby’s heart rate.”
B. “I’ll put both on your belly wherever it feels comfortable.”
C. “It doesn’t matter where we place them; we’ll just attach the belts.”
D. “We’ll only monitor your contractions today.”
.
What is “One goes over your fundus to monitor contractions, and one over the fetal back to monitor the baby’s heart rate.”
After vaginal delivery, which intervention should the nurse implement first?
A. Administer pain medication
B. Massage the fundus and monitor for bleeding
C. Encourage ambulation
D. Give the newborn a bath
es.
What is Massage the fundus and monitor for bleeding ?
A newborn is delivered vaginally. Which assessment should the nurse perform first?
A. Bath the baby
B. Measure weight and length
C. Assess airway, breathing, and circulation (ABC)
D. Give vitamin K injection
What is Assess airway, breathing, and circulation (ABC) ?
A nurse measures fundal height and obtains a result 3 cm greater than gestational age. What is the next action?
A. Reassess fundal height after the patient empties her bladder
B. Document as normal growth variation
C. Schedule a contraction stress test
D. Place the patient on continuous fetal monitoring
What is reassess fundal height after the patient empties her bladder?
Which statement from a pregnant client requires immediate follow-up related to lack of support?
A. “My mom lives two hours away, but I talk to her every day.”
B. “I don’t have anyone who can drive me to my prenatal appointments.”
C. “My partner doesn’t want to attend childbirth classes.”
D. “My siblings are busy but check on me sometimes.”
What is B. “I don’t have anyone who can drive me to my prenatal appointments.”
Rationale: Transportation barriers can lead to missed prenatal care, increasing risk for complications. This requires early intervention.
A provider requests placement of an internal fetal scalp electrode (FSE). Which condition must be present before placement?
A. Cervical dilation of at least 2 cm and ruptured membranes
B. Maternal bladder empty
C. Mild contractions only
D. Fetal heart rate above 160 bpm
What is?
Cervical dilation of at least 2 cm and ruptured membranes
The nurse is administering oxytocin during labor. Which action is priority?
A. Encourage ambulation
B. Monitor uterine contractions and FHR closely
C. Assess maternal temperature every 4 hours
D. Provide pain medication
What is Monitor uterine contractions and FHR closely ?
The nurse observes the umbilical cord with two arteries and one vein and no bleeding. What is the correct action?
A. Notify provider
B. Document as normal
C. Apply pressure
D. Clamp immediately
What is Document as normal?
Mention 3 reasons for the fundal height measurement to be too large?
What is macrosomia? Polyhidramnios? Multiple fetus? Miomas? Molar pregnancy? Error in measurement?
A nurse is completing a prenatal visit with a client who is 20 weeks pregnant. The client tells the nurse, “I feel overwhelmed. My partner travels a lot for work, and I don’t have much family nearby. I’m worried I won’t be able to handle everything.”
Which response by the nurse demonstrates appropriate psychosocial support?
A. “Many women feel stressed during pregnancy. You just need to stay positive.”
B. “I can refer you to prenatal support groups and resources in the community. Let’s talk about what kind of support you feel you need.”
C. “You should speak with your partner about being home more often during the pregnancy.”
D. “Try not to think about it too much. Stress is bad for the baby.”
What is “I can refer you to prenatal support groups and resources in the community. Let’s talk about what kind of support you feel you need.”?
Rationale:
B acknowledges the client’s concerns, encourages expression, and provides resources and community support, which is a key nursing intervention for psychosocial needs.
A nurse is explaining a non-stress test to a pregnant client at 32 weeks. Which statement is correct?
A. “It checks how your baby’s heart rate responds to uterine contractions.”
B. “It monitors your baby’s heart rate in response to fetal movement.”
C. “It measures the strength of your contractions.”
D. “It will tell us the exact birth date of your baby.”
What is “It monitors your baby’s heart rate in response to fetal movement.”
This type of vaginal discharge is red and present for one to three days following delivery.
What is Lochia Rubra?
During a sudden loud noise or head drop, the newborn extends arms and legs, then pulls them back in. This is:
What is the Moro reflex?