A nurse is caring for a client who is in active labor and experiencing shoulder dystocia.

Which of the following actions should the nurse take? (Select all that apply.).

Apply suprapubic pressure

Instruct the client to push with contractions

Assist the provider with McRoberts maneuver

Perform fundal massage

Administer oxygen via face mask.

Answer and Explanation

Correct Answer : A,C

Applying suprapubic pressure and assisting the provider with McRoberts maneuver are two nursing interventions that can help dislodge the impacted shoulder and facilitate the delivery of the baby.

Normal ranges for fetal heart rate are 110 to 160 beats per minute, and for maternal blood pressure are 110/70 to 140/90 mm Hg.

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Correct Answer is ["A"]

Explanation

A boggy uterus is a sign of uterine atony, which is the failure of the uterus to contract sufficiently after childbirth.

This can lead to excessive bleeding and postpartum hemorrhage.

A firm fundus at the umbilicus is a normal finding after delivery and indicates that the uterus is contracting well.

Excessive lochia rubra is also a sign of uterine atony and postpartum hemorrhage.Lochia rubra is the vaginal discharge composed of blood, mucus, and tissue from the placenta and the uterus lining that occurs after childbirth.

It is normal for the first 3 to 4 days, but it should gradually decrease in amount and change in color.

Clots larger than a quarter are abnormal and indicate excessive bleeding.

A pulse rate of 110/min is a sign of tachycardia, which can be caused by blood loss, infection, or pain.

A normal pulse rate for an adult is between 60 and 100 beats per minute.

A. Encourage fluid intake of at least 3 L per day B. Apply zinc oxide cream to the perineal area C. Insert an indwelling urinary catheter D. Teach pelvic floor exercises.

Correct Answer is B

Explanation

a vesicovaginal fistula is an abnormal opening that forms between the bladder and the wall of the vagina, causing urine to leak out of the vagina.Zinc oxide cream can help protect the skin from irritation and infection.

Normal ranges for fluid intake are about 2 to 3 liters per day for healthy adults, depending on age, activity level, and climate.Normal ranges for pelvic floor muscle strength are 10 to 12 contractions of 6 to 8 seconds each, with a rest period of 4 to 6 seconds between each contraction.

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A nurse is caring for a client who is in active labor and experiencing shoulder dystocia. Which of the following actions should the nurse take? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who had a prolonged labor and is at risk for uterine atony. Which of the following findings should indicate to the nurse that the client has this condition? Select all that apply.

Correct Answer is ["A"]

Explanation

A nurse is caring for a client who has prolonged and obstructed labor and develops a vesicovaginal fistula. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is B

Explanation

A nurse is assessing a client who is in labor and has been pushing for 3 hours with no progress. The nurse should identify that this client is at risk for which of the following complications? (Select all that apply.).

A gush of blood is noted with the rupture of membranes. On palpation, the uterus is soft (i.e., relaxed) and the patient is not reporting any pain. An FHR deceleration down to 90 bpm is noted. What does the nurse suspect has happened?

A nurse is reviewing the risk factors for uterine rupture with a group of nursing students. Which of the following risk factors should the nurse include? (Select all that apply.)

A nurse is reviewing the partograph of a client in labor. The nurse notes that the cervical dilation curve is above the alert line and below the action line. What does this indicate?

A nurse is reviewing the medical record of a client who is in labor and has cephalopelvic disproportion (CPD). Which of the following findings should the nurse expect to see in the record?

A nurse is caring for a client who has prolonged labor and is at risk for infection. Which of the following actions should the nurse take to reduce this risk? (Select all that apply.)

A nurse is evaluating a client who has prolonged and obstructed labor for signs of postpartum hemorrhage. Which of the following findings is an early indicator of postpartum hemorrhage?

A nurse is providing discharge teaching to a client who had a ruptured uterus and a hysterectomy during labor. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

A nurse is caring for a client who is in active labor and experiencing shoulder dystocia.

Which of the following actions should the nurse take? (Select all that apply.).