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
The correct answer is choice A. Manual resuscitation bag and B. An advanced airway kit.
Choice A rationale:
A manual resuscitation bag is essential in pediatric emergencies to provide immediate ventilation support if the child experiences respiratory failure or arrest. This device allows healthcare providers to manually deliver breaths to the patient, ensuring adequate oxygenation and ventilation until more advanced airway management can be established.
Choice B rationale:
An advanced airway kit is crucial for managing a difficult airway, especially in pediatric patients who may have anatomical differences making intubation challenging. This kit typically includes tools for endotracheal intubation, laryngeal mask airways, and other devices to secure the airway and ensure the child can breathe effectively.
Choice C rationale:
A dose of subcutaneous epinephrine is primarily used for treating severe allergic reactions or anaphylaxis. While it is a critical medication in emergencies involving anaphylaxis, it is not directly related to the immediate need for airway management and ventilation in this scenario.
Choice D rationale:
The child’s favorite toy can be helpful in calming and distracting the child during medical procedures, reducing anxiety and making the experience less traumatic. However, it is not a medical necessity for the placement of an intravenous line or for managing respiratory distress.
Choice E rationale:
Nebulized albuterol is used to treat bronchospasm and wheezing, commonly seen in asthma or reactive airway disease. While it is an important medication for managing respiratory symptoms, it does not address the immediate need for airway management and ventilation support in a critical situation.
Correct Answer is A
Explanation
Choice A rationale
Monitoring the capillary refill of the toes is crucial when a child has a long-leg cast applied. This is because it helps assess the adequacy of circulation to the foot, which can be compromised by the cast. If the capillary refill is delayed (more than 2 seconds), it could indicate poor blood flow to the area, which could lead to serious complications such as tissue necrosis.
Choice B rationale
Comparing the temperature of both legs can provide information about circulation and inflammation. However, it is not the most important action in this case. While a significant difference in temperature could indicate a problem, it is not as direct an indicator of circulatory status as capillary refill.
Choice C rationale
Observing for spontaneous movement can provide information about nerve function. If the child is not moving the toes, it could indicate nerve damage. However, lack of movement could also be due to discomfort from the cast and is not as direct an indicator of circulatory status as capillary refill.
Choice D rationale
Checking the femoral pulses can provide information about circulation to the leg. However, the femoral pulse is proximal to the cast and may not accurately reflect circulation to the foot. Therefore, it is not the most important action in this case.
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