A nurse is caring for a client who is having a vacuum-assisted birth.
Which of the following actions should the nurse take?
Inform the client that the vacuum cup will be positioned in front of the fetal ears.
Encourage the client to push during contractions.
Discontinue fetal monitoring during the procedure.
Administer a fluid bolus to ensure a full bladder during the procedure.
The Correct Answer is B
Choice A rationale
The vacuum cup for an assisted birth is strategically placed on the fetal occiput, which is the posterior aspect of the fetal skull, not in front of the fetal ears. Proper placement over the posterior fontanelle promotes traction directly on the bone, minimizing the risk of fetal scalp injury and ensuring efficient rotation and descent of the fetal head during traction. Positioning near the ears is incorrect and dangerous.
Choice B rationale
During a vacuum-assisted birth, the client is actively encouraged to push effectively with each uterine contraction, as the vacuum traction is applied only during a contraction. Maternal pushing augments the force of the vacuum device and facilitates the fetal head's descent through the birth canal, maximizing the procedure's success while minimizing the duration and number of pulls required for delivery.
Choice C rationale
Continuous fetal monitoring is absolutely essential throughout a vacuum-assisted birth procedure. It allows the nurse and provider to immediately assess the fetal heart rate (FHR) response to the procedure, identify potential complications like bradycardia or non-reassuring FHR patterns, and guide the discontinuation of the vacuum if fetal compromise is detected.
Choice D rationale
Administering a fluid bolus to ensure a full bladder is contraindicated during labor and birth. An empty bladder is preferred for fetal descent and to prevent obstruction of the birth canal. Furthermore, a full bladder can potentially be damaged by the descending fetal head, making bladder emptying (catheterization) common prior to assisted delivery if necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Acyclovir is an antiviral medication used primarily to treat herpes simplex virus (HSV) infections to prevent vertical transmission to the neonate. Group B Streptococcus (GBS) is a bacterium and is treated with antibiotics, specifically penicillin or ampicillin, administered intravenously during labor and delivery to prevent neonatal sepsis.
Choice B rationale
The Group B Streptococcus (GBS) culture is typically collected as a single screen between 36 weeks 0 days and 37 weeks 6 days of gestation from the lower vagina and perirectal area. This one-time positive result is sufficient to indicate the need for intrapartum antibiotic prophylaxis (IAP); repeat testing 24 hours later is not standard practice.
Choice C rationale
If the Group B Streptococcus (GBS) culture is positive, the client is considered colonized and requires intrapartum antibiotic prophylaxis (IAP), usually penicillin G, administered intravenously at the onset of labor or rupture of membranes. This reduces the risk of GBS transmission to the newborn, which can cause severe neonatal morbidity like sepsis or pneumonia.
Choice D rationale
The Group B Streptococcus (GBS) culture is a screening test obtained via a swab of the client's lower vagina and perirectal area, not a blood test. The GBS bacteria colonize these areas, and the swab is sent for culture and sensitivity to determine the need for prophylactic antibiotics during labor.
Correct Answer is B
Explanation
Choice A rationale
Asking about the fluid's color (clear, meconium-stained, bloody) provides information about fetal well-being and potential complications (like meconium aspiration), but it is a secondary assessment. While important, it does not supersede the need to immediately assess the most urgent physiological parameter of fetal status, which is the heart rate.
Choice B rationale
The rupture of membranes (water breaking) carries a risk of prolapsed umbilical cord, which can severely compromise fetal oxygenation by compressing the umbilical vessels. Determining the fetal heart rate (FHR) immediately is the priority action to identify signs of fetal distress, such as bradycardia (FHR <110 beats/min), indicating cord compression. The normal FHR range is 110-160 beats/min.
Choice C rationale
Monitoring cervical dilation is necessary to determine the stage and progress of labor. However, in the setting of ruptured membranes, assessing the immediate safety and stability of the fetus takes precedence over checking labor progress. A vaginal exam to check dilation is done after assessing FHR and ruling out immediate emergencies like cord prolapse.
Choice D rationale
Determining the vaginal pH with Nitrazine paper can confirm if the fluid is amniotic fluid (alkaline, pH 7.0-7.5) or urine/vaginal secretions (acidic). While this confirms the rupture of membranes, establishing the status of the fetus by assessing the FHR is the most critical and life-saving priority action to take first to prevent or quickly address fetal hypoxia.
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