A nurse is caring for a client who is in the second stage of labor.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

The condition of shoulder dystocia is correct because the retraction of the fetal head against the maternal perineum, also known as the "turtle sign," indicates that the fetal shoulders may be impacted behind the maternal symphysis pubis. The actions of initiating the McRoberts maneuver and applying suprapubic pressure are standard interventions to relieve shoulder dystocia. Monitoring the maternal perineum for tears is essential because the manipulation to resolve shoulder dystocia can cause significant maternal trauma. Monitoring fetal heart rate ensures that the fetus is not experiencing distress during the resolution of shoulder dystocia.

Actions and Parameters Rationale:

1. Initiating McRoberts maneuver helps to widen the pelvis and facilitate the release of the fetal shoulders by positioning the mother's thighs up toward her abdomen.
2. Applying suprapubic pressure aids in dislodging the fetal shoulder from behind the maternal symphysis pubis, easing delivery.
3. Monitoring maternal perineum for tears is important because the interventions used to resolve shoulder dystocia can cause tears or lacerations in the maternal tissue.
4. Continuous monitoring of fetal heart rate ensures the well-being of the fetus during the intervention, as shoulder dystocia can lead to fetal hypoxia.

Incorrect Conditions:

1. Malpresentation (B): The fetal head is already crowning, indicating that the fetus is in a cephalic presentation, not malpresentation.
2. Subinvolution of the uterus (C): This condition occurs postpartum, not during labor, and is characterized by delayed shrinking of the uterus back to its pre-pregnancy size.
3. Maternal perineal tear (D): While a tear may occur as a result of shoulder dystocia, the primary issue indicated by the retraction of the fetal head is shoulder dystocia itself, not just a perineal tear