A nurse is performing Leopold maneuvers on a patient in labor and determines the fetus is in an RSA position. What fetal presentations should the nurse document in the patient’s medical record?

Shoulder

Vertex

Mentum

Breech

Answer and Explanation

The Correct Answer is D

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale

The symptoms described, including the paradoxical movement of the chest wall (moving inward during inspiration and outward during expiration), are indicative of a flail chest, which is a life-threatening condition that occurs when a segment of the rib cage breaks due to trauma and becomes detached from the rest of the chest wall.

Choice B rationale

Hemothorax is a collection of blood in the space between the chest wall and the lung (the pleural cavity). It’s often caused by chest trauma. It does not cause the chest to move inward during inspiration and outward during expiration.

Choice C rationale

Atelectasis is a complete or partial collapse of the entire lung or area (lobe) of the lung. It does not cause the chest to move inward during inspiration and outward during expiration.

Choice D rationale

Pneumothorax is a collapsed lung. It does not cause the chest to move inward during inspiration and outward during expiration.

A. Increasing IV fluid rate B. Encouraging the client to sit up without assistance C. Administering antiemetic medication D. Monitoring respiratory rate closely E. Providing reassurance and calming interventions F. Checking electrolyte levels regularly

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

Action	Essential	Nonessential	Contraindicated
Increasing IV fluid rate		The current rate is prescribed by the provider; increasing it without further assessment could lead to complications.
Encouraging the client to sit up without assistance		The client feels faint upon sitting up and is unsteady, so this could be dangerous.
Administering antiemetic medication	Helpful but not immediately critical.
Monitoring respiratory rate closely	Crucial due to client's rapid breathing and anxiety.
Providing reassurance and calming interventions	Important due to client's anxiety and discomfort.
Checking electrolyte levels regularly	Essential for ongoing monitoring given the client's symptoms.

Essential

Monitoring respiratory rate closely: The client is breathing rapidly and appears anxious, making close monitoring crucial to ensure timely intervention and management of respiratory issues.
Providing reassurance and calming interventions: The client is anxious and discomforted. Providing reassurance and calming interventions is important to address their immediate emotional and psychological needs.
Checking electrolyte levels regularly: Given the client's symptoms and the need for ongoing monitoring, checking electrolyte levels is essential for managing their condition effectively.

Nonessential

Administering antiemetic medication: While helpful for managing nausea, this action is not immediately critical compared to other interventions that address more urgent needs.

Contraindicated

Encouraging the client to sit up without assistance: The client feels faint and is unsteady when sitting up. Encouraging them to sit up without assistance could be dangerous and may increase the risk of falls or injuries.
Increasing IV fluid rate: The current IV fluid rate is prescribed by the provider. Increasing it without further assessment could lead to complications and should be avoided unless directed by a healthcare provider.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is performing Leopold maneuvers on a patient in labor and determines the fetus is in an RSA position. What fetal presentations should the nurse document in the patient’s medical record?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

Essential

Nonessential

Contraindicated

A nurse is caring for a patient who is postoperative following abdominal surgery. The nurse discovers a loop of bowel protruding through an opening in the surgical incision. What should the nurse do?

A nurse is preparing to administer furosemide 40 mg IV. Available is furosemide 10 mg/1 mL. How many mL should the nurse administer per dose?

A nurse in the emergency department is attending to a patient exhibiting symptoms of a myocardial infarction. Which of the following actions should the nurse prioritize?

A nurse is preparing to replace a nearly empty container of total parenteral nutrition (TPN) for a patient. There has been a delay in receiving the new TPN solution from the pharmacy. Which of the following solutions should the nurse infuse until the next TPN solution is available?

A nurse has completed an informed consent form with a patient.The patient then states, “I have changed my mind and do not want to have the procedure done.”. What action should the nurse take?

A nurse is offering anticipatory guidance on child development to the parents of a toddler. Which developmental task should the nurse mention as being expected of a toddler?

A nurse is assisting a healthcare provider with a sterile procedure and is preparing to pour solution onto a sterile piece of gauze. In what sequence should the nurse perform the following steps when pouring the sterile solution?