A nurse is assisting with the care of a client who is in the second stage of labor.
The nurse observes retraction of the fetal head against the maternal perineum as the head is birthed.
Which of the following actions should the nurse take?
Prepare for the delivery of the shoulders.
Encourage the mother to push during the next contraction.
Call for additional medical support.
Administer pain relief medication.
The Correct Answer is A
Choice A rationale:
Normal progression of labor: After the fetal head is delivered, the shoulders typically follow immediately. The nurse should be prepared to assist with the delivery of the shoulders to ensure a safe and smooth birth process.
Significance of retraction: Retraction of the fetal head against the maternal perineum, also known as the "turtle sign," is a classic indicator of shoulder dystocia. While this sign does not guarantee shoulder dystocia, it warrants immediate preparation for potential management.
Anticipating shoulder dystocia: By anticipating the possibility of shoulder dystocia, the nurse can take proactive measures to minimize risks and facilitate delivery. These measures may include:
Positioning the mother appropriately (e.g., McRoberts maneuver)
- Applying suprapubic pressure
- Performing internal maneuvers (e.g., Rubin's maneuver)
- Breaking the clavicle (in extreme cases)
Choice B rationale:
Ineffective in shoulder dystocia: Encouraging the mother to push during the next contraction is not an effective intervention
for shoulder dystocia. In fact, excessive pushing can worsen the impaction of the shoulders and potentially lead to
complications such as fetal hypoxia, brachial plexus injury, or maternal perineal trauma.
Choice C rationale:
Necessary in confirmed dystocia: Calling for additional medical support is crucial if shoulder dystocia is confirmed. However,
immediate preparation for shoulder delivery should commence without delay, as prompt action is essential to prevent adverse
outcomes.
Choice D rationale:
Secondary concern: While pain relief medication may be administered for maternal comfort, it is not a priority intervention in
this situation. The primary focus should be on managing the potential shoulder dystocia and ensuring the safe delivery of the
baby.
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Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Umbilical cord compression is a serious condition that can deprive the fetus of oxygen and nutrients. It can occur during labor
due to various factors, such as excessive fetal movement, a long umbilical cord, or decreased amniotic fluid.
Key signs of umbilical cord compression include:
Variable decelerations: These are abrupt decreases in the fetal heart rate (FHR) that vary in duration, depth, and timing. They
are often caused by cord compression, as the compression temporarily reduces blood flow to the fetus.
Late decelerations: These are delayed decreases in the FHR that occur after the peak of a uterine contraction. They can also be
a sign of cord compression, as the compression can impair placental blood flow.
Loss of FHR variability: This refers to a decrease in the normal fluctuations of the FHR. It can be a sign of fetal distress,
including cord compression.
Immediate action is crucial when umbilical cord compression is suspected. The nurse should:
Notify the provider immediately.
Change the mother's position: This can help relieve pressure on the cord. Common positions include:
Lateral positioning (lying on the side)
Trendelenburg position (lying on the back with the head tilted down)
Knee-chest position (kneeling with the chest on the bed)
Administer oxygen to the mother: This can increase fetal oxygenation.
Prepare for possible interventions: These may include amnioinfusion (infusing fluid into the amniotic sac to increase fluid
volume), internal fetal monitoring, or cesarean delivery.
Choice B rationale:
Head compression is a common occurrence during labor as the fetal head descends through the birth canal. It usually does not
require intervention unless it causes significant changes in the FHR or other signs of fetal distress.
Choice C rationale:
Maternal opioid administration can affect the FHR, but it is not typically a cause for immediate concern unless there are
significant changes in the FHR or other signs of fetal distress. The nurse should continue to monitor the FHR closely and report
any concerns to the provider.
Choice D rationale:
Lateral decelerations are not a recognized pattern of fetal heart rate decelerations. The correct term for decelerations that
occur after the peak of a contraction is "late decelerations."
Correct Answer is C
Explanation
Choice A rationale:
Urinary retention is not a common sign of impending labor. In fact, it's more likely to occur in the early stages of pregnancy
due to hormonal changes and the pressure of the growing uterus on the bladder. As labor approaches, the baby's head often
descends into the pelvis, which can relieve some of the pressure on the bladder and make urination more frequent, not less
frequent.
Urinary retention can be a sign of other medical concerns, such as a urinary tract infection or problems with bladder function.
It's important to report any difficulty urinating to a healthcare provider for proper evaluation and treatment.
Choice B rationale:
A decrease in vaginal discharge is not typically associated with impending labor. On the contrary, many women notice an
increase in vaginal discharge, often referred to as "bloody show," as labor approaches. This discharge is typically pink or
brownish in color and may contain streaks of blood. It's caused by the release of the mucus plug that seals the cervix during
pregnancy.
A decrease in vaginal discharge could be a sign of other issues, such as a decrease in amniotic fluid or a yeast infection. It's
important to report any changes in vaginal discharge to a healthcare provider for assessment.
Choice D rationale:
A weight gain of 0.5 to 1.5 kilograms (1 to 3 pounds) is not a reliable sign of impending labor. Weight fluctuations are common
in late pregnancy due to factors such as fluid retention and changes in blood volume. Some women may even lose a small
amount of weight in the days leading up to labor.
While significant weight gain (more than 2 kilograms or 4 pounds in a week) could indicate a potential issue like preeclampsia,
a small weight gain or loss is not typically a cause for concern in terms of labor onset.
Choice C rationale:
A surge of energy, often referred to as "nesting instinct," is a common sign that labor may be approaching. This sudden burst of
energy can manifest as a strong urge to clean, organize, and prepare the home for the baby's arrival. It's thought to be caused
by a combination of hormonal changes and the body's natural instincts to prepare for childbirth.
While the exact timing of labor is unpredictable, experiencing a surge of energy, especially in conjunction with other signs like
increased Braxton Hicks contractions, lower back pain, or pelvic pressure, may suggest that labor is likely to start within the
next few days or weeks.
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