A woman is in the second stage of labor where the fetal head has just been born and the nurse observes the immediate retraction of the head against the perineum.
What action should the nurse expect to perform to assist the healthcare provider?
Prepare a vacuum.
Apply suprapubic pressure.
Apply fundal pressure.
Prepare forceps.
Prepare forceps.
The Correct Answer is B
Choice A rationale
Preparing a vacuum is not the first action to take in this situation. A vacuum-assisted delivery might be considered in some cases, but it’s not the immediate action when the fetal head retracts against the perineum.
Choice B rationale
Applying suprapubic pressure is the correct action. This situation describes shoulder dystocia, where the baby’s shoulder gets stuck behind the mother’s pelvic bone during delivery. Suprapubic pressure can help dislodge the baby’s shoulder and allow the delivery to proceed.
Choice C rationale
Applying fundal pressure is not recommended in this situation. Fundal pressure could potentially worsen shoulder dystocia and is generally avoided.
Choice D rationale
Preparing forceps is not the immediate action to take. Forceps may be used in some delivery situations, but in the case of shoulder dystocia, other maneuvers are tried first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Keeping plastic bags of ice in the freezer is not specifically indicative of successful management of hemophilia. While ice can be used to manage acute joint bleeds, it does not reflect the overall management of the condition.
Choice B rationale
Wearing extra pads when playing football could indicate an awareness of the risk of injury, but it does not necessarily reflect successful management of hemophilia. In fact, contact sports like football are generally not recommended for individuals with hemophilia due to the risk of bleeding.
Choice C rationale
Serving as a counselor at a camp for hemophiliacs could indicate successful management of hemophilia. It suggests that the individual has not only learned to manage their own condition, but is also able to provide guidance and support to others with the same condition.
Choice D rationale
Chewing food slowly to prevent injury to the gums is a precautionary measure, but it does not necessarily indicate successful management of hemophilia.
Correct Answer is C
Explanation
Choice A rationale
A heart rate of 58 beats/minute is within the normal range for adults, including those who have recently given birth. Therefore, there is no need to report this to the healthcare provider.
Choice B rationale
While assessing for excessive lochia is important in postpartum care, there is no indication from the given vital signs that this is necessary.
Choice C rationale
The vital signs provided are all within normal ranges for a postpartum patient. Therefore, the appropriate action would be to document these findings in the patient’s record.
Choice D rationale
There is no indication from the given vital signs that the patient has a fever or pain, so administering a PRN dose of acetaminophen is not necessary.
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