A nurse is caring for a client in the second stage of labor who is experiencing shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver.
What action should the nurse take?

Press firmly on the client’s suprapubic area.

Assist the client in pulling their knees toward their abdomen.

Apply pressure to the client’s fundus.

Move the client onto their hands and knees.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Applying firm pressure on the client’s suprapubic area is not part of the McRoberts maneuver. This action is more associated with the suprapubic pressure technique, which is another method used to manage shoulder dystocia.
Choice B rationale
The McRoberts maneuver involves having the client flex her hips against her abdomen. This is achieved by assisting the client in pulling her knees toward her abdomen.
Choice C rationale
Applying pressure to the client’s fundus is not part of the McRoberts maneuver and can be contraindicated as it may cause additional complications.

Choice D rationale
Moving the client onto their hands and knees is not part of the McRoberts maneuver. This position is more associated with the all-fours maneuver, also known as the Gaskin maneuver.

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Correct Answer is D

Explanation

Choice A rationale
A heart rate of 89/min is within the normal range for adults, and would not typically be a cause for concern.
Choice B rationale
A blood pressure of 120/70 mm Hg is considered normal for adults.
Choice C rationale
Moderate lochia serosa is a normal part of the postpartum period.
Choice D rationale
This is the correct answer. Cool, clammy skin can be a sign of postpartum hemorrhage, a serious condition that requires immediate medical attention.

A. A client who is at 10 weeks of gestation and reports frequent urination B. A client who is at 8 weeks of gestation and reports severe vomiting C. A client who is at 36 weeks of gestation and reports back pain following intercourse D. A client who is at 24 weeks of gestation and reports periodic tingling of the fingers

Correct Answer is B

Explanation

Choice A rationale
Frequent urination is a common symptom in early pregnancy due to the increased blood flow to the woman’s kidneys. This is a normal physiological change and does not require immediate attention.
Choice B rationale
Severe vomiting at 8 weeks of gestation could indicate hyperemesis gravidarum, a severe form of nausea and vomiting in pregnancy that can lead to dehydration and weight loss. This

condition requires immediate medical attention as it can have serious health implications for both the mother and the baby.
Choice C rationale
Back pain following intercourse at 36 weeks of gestation could be a sign of labor. However, it is not as urgent as severe vomiting in early pregnancy which can lead to dehydration.
Choice D rationale
Periodic tingling of the fingers at 24 weeks of gestation could be due to physiological changes in pregnancy such as fluid retention causing carpal tunnel syndrome. While this can be uncomfortable, it is not a medical emergency.

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A nurse is caring for a client in the second stage of labor who is experiencing shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver. What action should the nurse take?

Nursing Test Bank

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A nurse is caring for a client in the second stage of labor who is experiencing shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver.
What action should the nurse take?