During the second stage of labor, 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 anticipate performing to assist the healthcare provider?
Prepare 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 when the fetal head retracts against the perineum during the second stage of labor.
Choice B rationale
Applying suprapubic pressure can help guide the baby’s head out. This is a common practice during the second stage of labor when the baby’s head retracts against the perineum.
Choice C rationale
Applying fundal pressure is not typically done when the fetal head retracts against the perineum. Fundal pressure can be used to assist in the delivery of the baby, but it’s not the first action to take in this situation.
Choice D rationale
Preparing forceps is not the first action to take when the fetal head retracts against the perineum. Forceps are used to assist in the delivery of a baby, but only when necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Immediately after delivery, the breasts of a new mother are not likely to remain the same as before delivery. Hormonal changes during pregnancy prepare the breasts for lactation, and these changes do not typically revert immediately after delivery.
Choice B rationale
On the first postpartum day, the breasts of a new mother are most likely to be filling and secreting colostrum. Colostrum is the first form of milk produced by the mammary glands, and it usually starts to be produced during pregnancy and continues during the early days of breastfeeding.
Choice C rationale
An immediate let-down response is not typically observed on the first postpartum day. The letdown reflex, which releases milk from the breast, usually becomes more pronounced after the first few days of breastfeeding.
Choice D rationale
While the breasts may become larger due to milk production, they are not typically very tender to touch on the first postpartum day. Tenderness may occur later, especially if complications like engorgement or mastitis develop.
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."
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