A nurse is evaluating a patient who is suffering from prostatic hypertrophy.
What symptoms associated with urinary retention should the nurse anticipate? (Choose all that apply)

Choice A rationale

Standing directly in front of a patient who has a history of anger and aggression can be perceived as threatening and may escalate the situation.

Choice B rationale

Knowing the layout of the facility can help the nurse to plan for safe exits or to put barriers between themselves and the patient if needed.

Choice C rationale

Bringing security for all patient interactions can escalate the situation and should only be done if there is a clear threat to safety.

Choice D rationale

Providing immediate verbal feedback for escalating behavior can help to de-escalate the situation and reassure the patient.

Choice E rationale

Avoiding wearing necklaces during patient care can reduce the risk of injury to the nurse.

Choice A rationale

The shoulder is not the correct fetal presentation in this case. The shoulder presentation, also known as a transverse lie, occurs when the fetus is positioned horizontally in the uterus, and the shoulder is the presenting part. This is not the case in an RSA (Right Sacrum Anterior) position, which indicates a breech presentation.

Choice B rationale

The vertex presentation, also known as a cephalic presentation, occurs when the fetus is positioned head down in the uterus. However, in an RSA position, the fetus is in a breech presentation, not a vertex presentation.

Choice C rationale

The mentum (face) presentation is a rare type of fetal presentation where the neck of the fetus is hyperextended, and the face presents at the cervix. This is not the case in an RSA position, which indicates a breech presentation.

Choice D rationale

In an RSA (Right Sacrum Anterior) position, the fetus is in a breech presentation. This means that the buttocks or feet of the fetus are positioned to enter the birth canal first. Therefore, the nurse should document a breech presentation in the patient’s medical record.