A nurse is caring for a client who presents to a labor and delivery unit experiencing rapidly progressing labor. Which of the following is the priority action for the nurse to take?

The correct answer is D. Fetal engagement

A. Fetal position, fetal lie, and fetal attitude are important aspects of the fetal presentation but are not specific considerations when performing an amniotomy.

B. Fetal lie is the relationship between the long axis of the fetus and the long axis of the mother. It is not directly relevant to the consideration of amniotomy.

C. Fetal attitude refers to the relationship of the fetal body parts to each other. It is not a specific consideration for amniotomy.

D. Fetal engagement is the correct consideration prior to amniotomy.

Fetal engagement refers to the descent of the fetal presenting part into the pelvis. Before performing an amniotomy, it is important to confirm that the fetal head is engaged in the pelvis, ensuring a lower risk of cord prolapse.

Choice A Reason:

Placing a rolled towel beneath one of the client's hips may be helpful to tilt the client and alleviate pressure, but it is not the first action.

Choice B Reason:

Applying internal upward pressure to the presenting part using two gloved fingers is appropriate. This maneuver, known as "manual elevation of the presenting part," helps lift the presenting part off the prolapsed cord, preventing compression and maintaining blood flow to the fetus. This action should be performed while waiting for additional assistance and interventions.

Choice C Reason:

Administering oxygen is important for the well-being of the fetus, but the immediate focus is on relieving pressure on the umbilical cord.

Choice D Reason:

Increasing the infusion rate may be necessary later, but the immediate priority is to address the prolapsed cord and ensure fetal oxygenation.

4.A nurse is providing discharge teaching to the parents of a newborn about car seat safety. Which of the following instructions should the nurse Include?

A. Place the shoulder harness in the slots above the newborn's shoulders.

B. Place the retainer clip at the level of the newborn's armpits.

C. Place the newborn at a 60° angle in the car seat.

D. Place the newborn in a blanket before securing them in the car seat.

Explanation

The correct answer is choice B

Choice A Reason:

Placing the shoulder harness in the slots above the newborn's shoulders is incorrect. The harness should be threaded through the slots at or below the baby's shoulders to provide proper protection.

Choice B Reason:

Placing the retainer clip at the level of the newborn's armpits is correct. This is a critical safety measure to ensure that the harness straps are positioned correctly on the newborn. Placing the retainer clip at the level of the armpits helps secure the harness straps over the baby's shoulders and prevents them from slipping off.

Choice C Reason:

Placing the newborn at a 60° angle in the car seat is not a standard recommendation. The car seat should be installed according to the manufacturer's instructions, and the baby should be placed in a semi-reclined position, typically at a 45° angle, to ensure proper support for the newborn's head and airway.

Choice D Reason:

Placing the newborn in a blanket before securing them in the car seat is not recommended. Extra padding, including bulky clothing or blankets, should not be placed under the harness straps as it can compromise the effectiveness of the restraint system. The baby should be dressed in thin layers, and if additional warmth is needed, a blanket can be placed over the baby after securing them in the car seat.