A nurse is caring for a client who is in the second stage of labor. The nurse observes retraction of the fetal head against the maternal perineum as the head is birthed.
Which condition is the client most likely experiencing?

Shoulder dystocia.

Breech presentation.

Placenta previa.

Uterine rupture.

Answer and Explanation

The Correct Answer is A

The correct answer is A. Shoulder dystocia. Retraction of the fetal head against the maternal perineum as the head is birthed is a classic sign of shoulder dystocia. This is a birth complication where the baby’s shoulder gets stuck behind the mother’s pelvic bone during delivery.

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Correct Answer is B

Explanation

Choice A rationale
While Type 1 diabetes is a significant health concern, it is not the most prevalent form of diabetes. Type 2 diabetes is more common, affecting a larger proportion of the population.
Choice B rationale
Type 2 diabetes often remains undiagnosed because its symptoms can be subtle and develop slowly. People with Type 2 diabetes may not recognize these symptoms as signs of high blood sugar, leading to a delay in diagnosis and treatment.
Choice C rationale
Type 1 diabetes cannot transition to Type 2 diabetes. These are distinct conditions with different underlying causes. Type 1 diabetes is an autoimmune condition, while Type 2 diabetes is primarily associated with lifestyle factors and genetic predisposition.
Choice D rationale
Gestational diabetes mellitus (GDM) does not imply that the woman will require insulin treatment until 6 weeks postpartum. While some women with GDM may require insulin during pregnancy, this is not always the case. Furthermore, GDM usually resolves after delivery.

A. A client who has missed a menstrual cycle and reports vaginal spotting. B. A client who is at 28 weeks of gestation and reports painless vaginal bleeding. C. A client who is at 38 weeks of gestation and reports symptoms of a cough and fever. D. A client who is at 14 weeks of gestation and reports experiencing nausea and vomiting.

Correct Answer is B

Explanation

Choice A rationale
Missing a menstrual cycle and reporting vaginal spotting could indicate early pregnancy or other non-emergency conditions. While this client should be evaluated, it is not the highest priority.
Choice B rationale
A client at 28 weeks of gestation reporting painless vaginal bleeding could be experiencing placenta previa or placental abruption, both of which are obstetric emergencies. This client should be prioritized for immediate evaluation.
Choice C rationale
A client at 38 weeks of gestation reporting symptoms of a cough and fever may have an upper respiratory infection. While this should be evaluated, it is not the highest priority unless the client is in distress.
Choice D rationale
Nausea and vomiting are common in early pregnancy. A client at 14 weeks of gestation reporting these symptoms would need evaluation, but it is not the highest priority.

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A nurse is caring for a client who is in the second stage of labor. The nurse observes retraction of the fetal head against the maternal perineum as the head is birthed. Which condition is the client most likely experiencing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In the context of diabetes incidence and classification, which statement should maternity nurses be aware of?

Correct Answer is B

Explanation

As a nurse in an antepartum unit performing triage, which client should be prioritized?

Correct Answer is B

Explanation

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A nurse is caring for a client who is in the second stage of labor. The nurse observes retraction of the fetal head against the maternal perineum as the head is birthed.
Which condition is the client most likely experiencing?