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 B
Explanation
The correct answer is choice B: Thick, muffled voice.
Choice B rationale: A thick, muffled voice is a characteristic symptom of epiglottitis. The inflammation and swelling of the epiglottis cause an obstruction in the airway, leading to changes in the child's voice quality.
Choice A rationale: High-pitched wheezing is typically associated with conditions affecting the lower airways, such as asthma or bronchiolitis. Epiglottitis primarily affects the upper airway, causing stridor (a high-pitched, harsh sound during inhalation) rather than wheezing.
Choice C rationale: Purulent nasal discharge is not a typical symptom of epiglottitis. Epiglottitis usually presents with minimal or no secretions, while purulent discharge is more commonly seen in bacterial infections like sinusitis or pneumonia.
Choice D rationale: A productive cough is not a common symptom of epiglottitis. Coughing is associated with conditions affecting the lower respiratory tract, such as bronchitis or pneumonia. Epiglottitis primarily affects the upper airway, causing difficulty breathing and a characteristic "thick, muffled voice."
Correct Answer is C
Explanation
Choice A rationale
While using gestures with 1 to 2 word sentences is a developmental milestone, it is typically seen in younger children, around the age of 212.
Choice B rationale
Using 1 word sentences is a developmental milestone usually achieved by children around the age of 112. By the age of 3, children are typically able to speak in simple sentences with four or more words.
Choice C rationale
Speaking in simple sentences with four or more words is a typical developmental milestone for a 3-year-old child. They are able to express their thoughts more clearly and engage in conversations.
Choice D rationale
Recognizing most letters and numbers is a skill that is typically developed around the age of 4 or 512. Therefore, expecting a 3-year-old child to recognize most letters and numbers might be too advanced for their developmental stage.
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