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 the skin incision moist by periodically wetting the dressing is not the recommended care for a myelomeningocele surgical repair. The dressing needs to be kept dry to prevent infection and promote healing.
Choice B rationale
Removing the tape rapidly from the edges of the dressing during a change is not advised. This could potentially damage the skin and disrupt the healing process.
Choice C rationale
An intact dressing protects the incision from fecal contamination, which is crucial in preventing infection. This statement indicates an understanding of the procedure.
Choice D rationale
While it’s important to keep the dressing dry to ensure easy removal of sutures, it’s not the primary concern. The main goal is to protect the incision from contamination.
Correct Answer is ["B","E"]
Explanation
Choice A rationale
Both mother and daughter shedding tears of joy and gratitude may not necessarily indicate a healthy psychosocial adaptation. While it could be a sign of relief or happiness, it could also be a response to stress or fear.
Choice B rationale
The mother expressing her full support for her daughter can be a positive sign of psychosocial adaptation. Support from family members can play a crucial role in coping with and adapting to health-related challenges.
Choice C rationale
The mother appearing sad does not necessarily indicate a healthy psychosocial adaptation. It could be a normal reaction to her daughter’s discomfort, but it could also suggest that she is struggling to cope with the situation.
Choice D rationale
The patient giving birth to a healthy baby boy is not relevant to the question as it does not provide information about the psychosocial adaptation of the mother or the daughter.
Choice E rationale
The mother commending her daughter can be a positive sign of psychosocial adaptation. Positive reinforcement can help individuals cope with challenging situations and foster a sense of self-efficacy.
Choice F rationale
Both mother and daughter gently touching the baby’s cheek is not relevant to the question as it does not provide information about the psychosocial adaptation of the mother or the daughter.
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