A nurse is preparing to perform a vacuum extraction for a client who has an obstructed labor due to a face presentation.
Which of the following actions should the nurse take? (Select all that apply.).
Obtain informed consent from the client
Administer prophylactic antibiotics to the client
Apply traction to the vacuum cup during contractions
Release the vacuum cup after every three pulls
Monitor the fetal heart rate continuously.
Correct Answer : A,E
The nurse should obtain informed consent from the client before performing a vacuum extraction, as it is an operative vaginal delivery that carries some risks for the mother and the baby. The nurse should also monitor the fetal heart rate continuously during the procedure, as vacuum extraction can cause fetal distress or scalp injuries.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is because the fetal head descent is below the alert line but above the action line on the partograph.The alert line indicates the average rate of cervical dilation of 1 cm per hour, and the action line is 4 hours to the right of the alert line.If the labor curve crosses to the right of the alert line, it means that the labor is slow and needs closer monitoring or referral.If the labor curve crosses to the right of the action line, it means that the labor is obstructed or prolonged and needs intervention such as oxytocin augmentation or cesarean delivery.
Correct Answer is A
Explanation
This is a complication that can occur when the baby’s head is delivered but one or both shoulders becomes “stuck” behind the pelvic bone.This can happen when the baby is too large or out of position when entering the pelvis, which are possible causes of cephalopelvic disproportion (CPD).
Normal ranges for fetal head circumference are 32 to 38 cm at term.
Normal ranges for maternal pelvic inlet diameter are 11 to 13 cm for anteroposterior diameter and 13 to 14 cm for transverse diameter.
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