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    2-Leopolds Maneuver and FHT FH

    Uploaded by

    Jirah Dawal
    This document contains a checklist for assessing a pregnant patient, including performing Leopold's maneuvers to determine fetal presentation, measuring fundal height, and locating the fetal heart tone. The checklist includes 35 steps divided into sections on objective, materials, procedure, evaluation, documentation, and references. It provides guidance to nursing students on correctly conducting an assessment of a pregnant patient and documenting findings.

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    © All Rights Reserved
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    2-Leopolds Maneuver and FHT FH

    Uploaded by

    Jirah Dawal
    13 views4 pages
    This document contains a checklist for assessing a pregnant patient, including performing Leopold's maneuvers to determine fetal presentation, measuring fundal height, and locating the fetal heart tone. The checklist includes 35 steps divided into sections on objective, materials, procedure, evaluation, documentation, and references. It provides guidance to nursing students on correctly conducting an assessment of a pregnant patient and documenting findings.

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    This document contains a checklist for assessing a pregnant patient, including performing Leopold's maneuvers to determine fetal presentation, measuring fundal height, and locating the fetal heart tone. The checklist includes 35 steps divided into sections on objective, materials, procedure, evaluation, documentation, and references. It provides guidance to nursing students on correctly conducting an assessment of a pregnant patient and documenting findings.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    13 views4 pages

    2-Leopolds Maneuver and FHT FH

    Uploaded by

    Jirah Dawal
    This document contains a checklist for assessing a pregnant patient, including performing Leopold's maneuvers to determine fetal presentation, measuring fundal height, and locating the fetal heart tone. The checklist includes 35 steps divided into sections on objective, materials, procedure, evaluation, documentation, and references. It provides guidance to nursing students on correctly conducting an assessment of a pregnant patient and documenting findings.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 4

    COLLEGE OF NURSING

    NAME: _________________________________________________ DATE: _______________________


    BLOCK: ________________________________________________ SCORE: ______________________
    CLINICAL INSTRUCTOR: __________________________________________________________________

    LEOPOLD’S MANUEVER, FUNDIC HEIGHT MEASUREMENT AND LOCATING


    FETAL HEART TONE
    PROCEDURE CHECKLIST

    I. Objective/s
    - To determine fetal presentation and position
    - Assess fetal growth and development of a fetal well being
    - Locate and assess fetal heart tone
    II. Materials/equipment
    - Pair of gloves
    - Stethoscope
    - Tape measure
    III. Procedure Steps. Check Done or Not done. The student DONE NOT REMARKS
    is expected to perform the following DONE
    1 0

    1. Assemble all necessary equipment


    2. Introduce self and verify client’s identity
    3. Close room doors and windows, draw room divider. Provide
    privacy
    A. Assessment
    4. Observe abdomen for longest diameter and fetal movement
    5. Skin irritation and inflammation
    6. Appearance of fatigue and apprehension
    7. Check home based-mothers record (diagnostic exam results)
    B. Planning
    8. At the end of the procedure,
    A. Fetal presentation and position are determined
    B. Client’s age of gestation will be validated
    C. Fetal heart tone is located and assessed
    C. Implementation
    9. Explain the maneuvers to the client and the rationale for each step
    as it is performed.
    Rationale: Explanation allay anxiety and enhances cooperation.
    Giving information, teaches the client, and reassures her when the
    assessment findings are normal
    10. Instruct to empty the bladder
    Rationale; Decreases discomfort of full bladder during palpation
    and improves ability to feel fetal parts in the suprapubic area.
    11. Wash hand and put-on gloves correctly
    Rationale: Prevents transmission of microorganism.
    12. Position the client in supine with knees slightly flexed
    Rationale: Knee flexion helps the client relax her abdominal

    Checklist for:: Date Effective Date Revised Prepared and Revised By: Approved by:
    Page - 1 -
    Maternal and Child 2nd Semester January 2021 Ms. Melody S.Yanos, RN,MAN Dr. Almira A. Tenorio, RN, MAN, MAEd of 3
    Health SY 2020-2021 Ms. Bernice U. Caliwagan, RN MAN Dean
    Faculty
    COLLEGE OF NURSING

    muscles to enhance palpation. Uterine displacement prevents


    aorto-caval compression which could reduce blood flow to the
    placenta
    13. Stand beside the client, facing her head, with your dominant hand
    nearest her.
    Rationale: the first three maneuvers are most easily performed in
    this position
    D. First Maneuver (FUNDIC GRIP) TO DETERMINE WHAT
    OCCUPIES THE FUNDUS
    14. Palpate the superior surface of the fundus. The breech (buttocks) is
    softer and more irregular in shape than the head. Moving the
    breech also moves the fetal truck. The head is harder and has a
    round, uniform shape. The head can be moved without moving the
    entire fetal trunk.
    Rationale: Distinguishes between a cephalic and breech
    presentation. If the fetus is in a cephalic presentation, the breech is
    felt in the fundus. If the presentation is breech head is felt in the
    fundus
    E. Second Maneuver (UMBILICAL GRIP) TO DETERMINE
    FETAL BACK
    15. Still facing the head part and palms of each hand on either side of
    the abdomen
    16. Hold the left hand steady on one side of the uterus while palpating
    the opposite side of the uterus with the right hand. Then hold the
    right hand steady while palpating the opposite side of the uterus
    with the left hand. The fetal back is a smooth, convex surface. The
    fetal arms and legs feel nodular, and fetus often moves them
    during palpation
    Rationale: Determines on which side of the uterus is the back and
    on which are the fetal arms and legs (small parts)
    F. Third Maneuver (PAWLICK’S GRIP) TO DETERMINE THE
    PART OF THE FETUS AT THE INLET OR PRESENTATION
    AND Its MOBILITY
    17. Palpate the suprapubic area. Gently grasp the lower portion of the
    abdomen just above the symphysis pubis between thumb and index
    finger. If a breech was palpated in the fundus, expect a hard,
    rounded head in this area. Attempt to grasp the presenting part
    gently between the thumb and fingers. If the presenting part is not
    engaged, the grasping movement of the fingers moves iT upward
    in the uterus.
    Rationale: Confirms the presentation determined in the first
    maneuver. Determines whether the presenting part is engaged
    (widest diameter at or below a zero station) in maternal pelvis.

    Omit the fourth maneuver if the fetus is in a breech presentation


    Rationale: Is performed only in a cephalic presentation to
    determine whether the fetal head is fixed
    G. Fourth Maneuver (PELVIC GRIP) TO DETERMINE FETAL
    ATTITUDE, DONE ONLY IS PRESENTATION IS IN
    CEPHALIC
    18. The examiner will now face the foot part
    Rationale: Is most easily performed in this position
    19. Place finger pads of each hand on both sides of the uterus
    approximately 2 inches above the inguinal ligaments
    Checklist for:: Date Effective Date Revised Prepared and Revised By: Approved by:
    Page - 2 -
    Maternal and Child 2nd Semester January 2021 Ms. Melody S.Yanos, RN,MAN Dr. Almira A. Tenorio, RN, MAN, MAEd of 3
    Health SY 2020-2021 Ms. Bernice U. Caliwagan, RN MAN Dean
    Faculty
    COLLEGE OF NURSING

    20. Press downward then inward to the direction of the birth canal
    allowing fingers to be carried downward
    21. Locate the fetal brow (prominence)
    • Good flexion/attitude- position of fetal brow is
    lined with the fetal extremities
    • Poor flexion/attitude- fetal brow is in lined with the
    fetal back
    H. Take the fetal heart tone
    22. Locate fetal back
    23. Use the bell side of the stethoscope
    24. Apply gentle pressure on the stethoscope while the other hand
    supports the opposite side of the abdomen
    25. Differentiate correctly fetal heart tones from other maternal sounds
    26. Take and count the FHT in between contractions in one full minute
    27. Take note of the quality of the fetal heart tone
    I. Fundic Height Measurement
    28. Warm hands
    29. Measure from the top of the symphysis pubis to the notch of the
    uterine fundus correctly
    30. Place the zero line of the tape measure on the anterior border of the
    symphysis pubis
    31. Stretch the tape measures midline of the abdomen to the top of the
    fundus
    32. Position the patient back to the position of comfort and assist
    mother as she gets up and down from the examining table. Discard
    PPE and perform hand hygiene
    J. Evaluation
    33. At the end of the procedure,
    a. Fetal presentation and position are determined
    b. Client’s age of gestation was validated
    c. Fetal heart tone is located and assessed
    d. Client is comfortable and participated in the procedure
    K. Documentation
    34. Validate data gathered for accuracy, reliability and completeness.
    Document and record findings accurately.
    35. Refer client to physician if,
    - Breech presentation
    - Fundic height is inappropriate with the age of gestation
    - FHT <110bpm or > 160 bpm
    Evaluator’s name and signature: Score:
    _____________
    /35

    REFERENCE:

    Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family, Adele Pillitteri ,7th
    Edition, Volume 1

    Checklist for:: Date Effective Date Revised Prepared and Revised By: Approved by:
    Page - 3 -
    Maternal and Child 2nd Semester January 2021 Ms. Melody S.Yanos, RN,MAN Dr. Almira A. Tenorio, RN, MAN, MAEd of 3
    Health SY 2020-2021 Ms. Bernice U. Caliwagan, RN MAN Dean
    Faculty
    COLLEGE OF NURSING

    Remarks:
    __________________________________________________________________________________________
    __________________________________________________________________________________________

    Evaluated by: Student conforme:

    _______________________________ ________________________________
    Clinical Instructor Name and Signature Student’s Signature

    Checklist for:: Date Effective Date Revised Prepared and Revised By: Approved by:
    Page - 4 -
    Maternal and Child 2nd Semester January 2021 Ms. Melody S.Yanos, RN,MAN Dr. Almira A. Tenorio, RN, MAN, MAEd of 3
    Health SY 2020-2021 Ms. Bernice U. Caliwagan, RN MAN Dean
    Faculty

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