A nurse is assisting with the care of a client who is in the second stage of labor.
The nurse observes retraction of the fetal head against the maternal perineum as the head is birthed.
Which of the following actions should the nurse take?
Encourage the mother to push during the next contraction.
Prepare for immediate delivery of the baby.
Call for additional medical support.
Administer pain relief medication.
The Correct Answer is C
Choice A rationale:
Encouraging the mother to push during the next contraction is not the appropriate action in this situation. Retraction of the
fetal head against the maternal perineum is a sign of shoulder dystocia, a serious obstetric emergency that requires immediate
intervention. Pushing could potentially worsen the situation by further impacting the anterior shoulder against the maternal
pubic symphysis.
Choice B rationale:
While preparing for immediate delivery of the baby may be necessary in some cases of shoulder dystocia, it is not the first
priority. The initial focus should be on relieving the impaction of the anterior shoulder and facilitating the safe delivery of the
baby. This often requires additional maneuvers and medical support.
Choice C rationale:
Calling for additional medical support is the most appropriate action in this situation. Shoulder dystocia can be a complex and
challenging emergency, and it's crucial to have experienced healthcare providers available to assist with the delivery.
Additional personnel can provide support with various maneuvers, fetal monitoring, and management of potential
complications.
Choice D rationale:
Administering pain relief medication is not a priority in this situation. While pain management is important during labor, it
should not take precedence over addressing the immediate obstetric emergency. The focus should be on resolving the
shoulder dystocia and ensuring a safe delivery.
Additional notes:
It's important to note that shoulder dystocia is a relatively uncommon complication, occurring in approximately 0.5-1% of all
vaginal births. However, it's a potentially serious emergency that can lead to significant complications for both the mother and
baby, such as brachial plexus injury, hypoxic-ischemic encephalopathy, and postpartum hemorrhage.
Early recognition and prompt intervention are crucial for optimizing outcomes in cases of shoulder dystocia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A
Choice A rationale: A distended bladder can displace the uterus upward and to the side, preventing proper uterine involution and increasing risk of postpartum hemorrhage.
Choice B rationale: Blood pressure of 130/84 mm Hg is within normal postpartum range and does not indicate urinary retention or bladder distention.
Choice C rationale: Moderate lochia rubra is expected postpartum and reflects normal uterine shedding, not urinary status.
Choice D rationale: Moderate labial swelling may occur from delivery trauma but does not directly indicate bladder fullness or urinary retention.
Correct Answer is D
Explanation
Choice A rationale:
Evaluating the side effects of analgesia is not the priority action in this situation. While it's important to assess for potential
side effects, the client's immediate need to use the bathroom takes precedence.
Analgesia might contribute to urinary retention in some cases, but it's not the most likely reason for the client's request.
Promptly addressing the client's need to void helps prevent bladder distention, discomfort, and potential urinary tract
infections.
Choice B rationale:
Using a wheelchair is not necessary in most cases after a vaginal birth.
Early ambulation is generally encouraged to promote circulation, prevent blood clots, and aid in recovery.
Requiring a wheelchair could delay the client's ability to void and might make her feel less independent.
Choice C rationale:
Advising the client to remain in bed is not recommended practice after a vaginal birth.
Prolonged bed rest can increase the risk of complications, such as blood clots, muscle weakness, and delayed bowel function.
Early ambulation, as tolerated, is crucial for promoting physical recovery and preventing postpartum complications.
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