A nurse in an obstetrics clinic is caring for a client.

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Exhibit 1

Nurses' Notes

Initial visit, 1340:

29-year-old gravida 2, para 0 client presents with report of a positive home pregnancy test from 2 weeks ago. Last menstrual period was 7 weeks ago. Urine human chorionic gonadotropin (hCG) positive. Client reports vomiting several times a day over the last 2 weeks and states, "I'm a vegetarian and I don't usually eat a lot of protein, but it's still hard to keep anything down." Decreased skin turgor noted, oral mucous membranes moist. Weight 79.4 kg (175 lb).

Exhibit 2

Vital Signs

Initial visit, 1330:

• Heart rate 110/min
• Respiratory rate 18/min
• Blood pressure 104/66 mm Hg
• Temperature 36.6° C (97.9° F)
• Oxygen saturation 99% on room air
• Continuation of above exhibit

Exhibit 3

The nurse is reviewing the client's assessment findings and laboratory results.

Laboratory Results

Initial visit, 1600:

• WBC count 7,500/mm3 (5,000 to 10,000/mm3)
• Hgb 10.2 g/dL (11 to 16 g/dL)
• Hct 45% (33% to 47%)
• Platelets 360,000/mm3 (150,000 to 400,000/mm3)
• Sodium 136 mEq/L (136 to 145 mEq/L)
• Potassium 3.3 mEq/L (3.5 to 5 mEq/L)
• BUN 28 mg/dL (10 to 20 mg/dL)

Urinalysis:

• Appearance clear (clear)
• Color dark amber (pale yellow amber)
• pH 7.9 (4.6 to 8)
• Protein 4 mg/dL (0 to 8 mg/dL)
• Specific gravity 1.045 (1.005 to 1.03)
• Leukocyte esterase negative (negative)
• Nitrites none (none)

A. Move the client onto their hands and knees.

This action refers to the Gaskin maneuver, which involves changing the maternal position to help alleviate shoulder dystocia during childbirth. By positioning the client on their hands and knees, gravity assists in changing the orientation of the pelvis, potentially allowing more space for the baby to be delivered. While the Gaskin maneuver can be effective in some cases of shoulder dystocia, it is not the McRoberts maneuver.

B. Press firmly on the client's suprapubic area.

This action describes the Rubin maneuver, another technique used to address shoulder dystocia. With the Rubin maneuver, pressure is applied to the anterior shoulder of the fetus, aiming to rotate it into an oblique diameter, which may help dislodge the shoulder from behind the symphysis pubis. While the Rubin maneuver can be helpful in certain cases of shoulder dystocia, it is not the McRoberts maneuver.

C. Apply pressure to the client's fundus.

Applying pressure to the client's fundus is not part of the McRoberts maneuver. In fact, this action is not recommended for managing shoulder dystocia as it could potentially worsen the situation by causing further impaction of the baby's shoulder against the mother's pubic bone.

D. Assist the client in pulling their knees toward their abdomen.

This is the correct action corresponding to the McRoberts maneuver. During the McRoberts maneuver, the nurse assists the client in flexing their hips sharply toward their abdomen. This action helps to widen the pelvic outlet and may facilitate the release of the impacted shoulder, allowing for easier delivery of the baby. The McRoberts maneuver is one of the primary maneuvers used to manage shoulder dystocia during childbirth.

A. Weight loss of 3%:

Newborns commonly experience weight loss in the first few days of life due to factors such as loss of excess fluid and adjustment to feeding. A weight loss of up to 7-10% in the first week is considered normal. Therefore, a weight loss of 3% alone, while notable, is not typically concerning enough to require immediate intervention. However, it should be monitored closely to ensure that the newborn is receiving adequate nutrition and hydration.

B. Voided one time since birth:

Newborns typically pass urine within the first 24 hours after birth. However, the frequency of voiding can vary, and it is not uncommon for a newborn to void only once in the first 24 hours. While it is important for newborns to void regularly to ensure adequate hydration and renal function, voiding once in the first 24 hours may not necessarily indicate a problem, especially if the newborn is breastfeeding. Therefore, while this finding should be monitored, it may not require immediate intervention.

C. Central cyanosis:

Central cyanosis, characterized by bluish discoloration of the lips, tongue, and mucous membranes, indicates inadequate oxygenation of the blood. It suggests a potential respiratory or cardiac problem that requires immediate evaluation and intervention to ensure adequate oxygenation and prevent complications. Central cyanosis is a concerning finding in newborns and warrants prompt attention from healthcare providers to determine the underlying cause and initiate appropriate treatment.

D. Apical pulse rate of 156/min:

The normal range for a newborn's heart rate is typically 120-160 beats per minute. An apical pulse rate of 156/min falls within this range and is not necessarily indicative of a problem, especially if the newborn is active or crying. While variations in heart rate can occur, a rate of 156/min alone may not be alarming. However, it should be monitored for any changes or trends outside the normal range as part of routine newborn assessment.