A nurse is caring for a client who is in the second stage of labor and is experiencing a shoulder dystocia.
The provider instructs the nurse to perform the McRoberts maneuver.
Which of the following actions should the nurse take?
Assist the client in pulling their knees toward their abdomen.
Press firmly on the client's suprapubic area.
Move the client onto their hands and knees.
Apply pressure to the client's fundus.
The Correct Answer is A
Choice A rationale:
The McRoberts maneuver involves an obstetrician or other healthcare provider flexing the thighs of a pregnant person toward their abdomen. This maneuver helps to rotate the pelvis and open the sacrum to release the baby’s shoulder.
Choice B rationale:
Applying pressure on the client’s suprapubic area is not part of the McRoberts maneuver. However, when coupled with suprapubic pressure, the effectiveness of the McRoberts maneuver increases to 90%1.
Choice C rationale:
Moving the client onto their hands and knees is not part of the McRoberts maneuver. The maneuver involves pressing the client’s legs against their abdomen.
Choice D rationale:
Applying pressure to the client’s fundus is not part of the McRoberts maneuver. The maneuver involves pressing the client’s legs against their abdomen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. Single palmar creases.
Choice A rationale: Single palmar creases (also known as simian creases) can be associated with certain genetic conditions, such as Down syndrome. The presence of this finding in a newborn should prompt further investigation and reporting to the healthcare provider for additional assessment and possible genetic testing.
Choice B rationale: Rust-stained urine in a newborn is typically caused by uric acid crystals, which are common and not considered abnormal during the first few days of life. This condition usually resolves without intervention, and it does not require reporting to the provider unless it persists or is accompanied by other symptoms.
Choice C rationale: Transient circumoral cyanosis is a common finding in newborns, especially when crying or feeding. It usually resolves on its own and is not considered an alarming sign unless it persists or is associated with central cyanosis or other signs of respiratory distress.
Choice D rationale: Subconjunctival hemorrhage is a common finding in newborns, usually resulting from the pressure changes during delivery. It typically resolves on its own within a few weeks and does not require reporting to the provider unless there are signs of other underlying conditions.
Correct Answer is B
Explanation
Choice A rationale:
Asking if the partner is pressuring the client to have sex is important, but it’s not the most relevant question when a client requests birth control.
Choice B rationale:
Asking what the client knows about contraception is the most relevant question. It allows the nurse to assess the client’s knowledge and provide appropriate education.
Choice C rationale:
Asking if the client is sure their partner loves them is not relevant to the client’s request for birth control.
Choice D rationale:
Asking why the client is requesting birth control is important, but it’s not as relevant as assessing the client’s knowledge about contraception.
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