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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Three fingerbreadths above the umbilicus is too high for the uterine fundus to be at 12 hours postpartum. Immediately after delivery, the fundus is typically at the level of the umbilicus. It then descends approximately one fingerbreadth per day.
If the fundus is found to be three fingerbreadths above the umbilicus at 12 hours postpartum, it could be a sign of uterine atony, which is a serious condition that can lead to postpartum hemorrhage.
Choice C rationale:
One fingerbreadth above the symphysis pubis is too low for the uterine fundus to be at 12 hours postpartum. This would be more consistent with a woman who is several days postpartum.
Choice D rationale:
One fingerbreadth below the umbilicus is also too low for the uterine fundus to be at 12 hours postpartum. This would be more consistent with a woman who is 1-2 days postpartum.
Correct Answer is D
Explanation
Rationale for Choice A:
Nipple shields are typically recommended for breastfeeding mothers experiencing nipple pain or thrush. While the client may
be experiencing some breast engorgement due to the hard and warm feeling, there is no indication of nipple pain or thrush.
Therefore, using a nipple shield is not the most appropriate recommendation in this case.
Rationale for Choice B:
Obtaining a prescription for an antibiotic is not warranted at this time. While mastitis, a breast infection, can occur
postpartum, the client's symptoms of moderate lochia rubra and firm, warm breasts are not specific enough to indicate
mastitis. Additionally, unnecessary antibiotic use should be avoided as it can contribute to antibiotic resistance.
Rationale for Choice C:
Applying a heating pad to the breasts may initially provide some comfort, but it can worsen engorgement and inflammation.
Heat stimulates milk production, which can further contribute to the client's discomfort. Applying cold compresses or ice
packs would be a more appropriate intervention for reducing inflammation and breast engorgement.
Rationale for Choice D:
Expressing milk from both breasts is the most appropriate recommendation for the client experiencing breast engorgement.
Regular milk removal helps to reduce milk build-up, alleviate engorgement, and decrease the risk of mastitis. The nurse can
teach the client proper handwashing techniques and breast massage strategies to facilitate effective milk expression.
Additionally, the nurse can encourage the client to breastfeed frequently, as this is the most efficient way to remove milk and
prevent engorgement.
Additional Notes:
The client's postpartum day (3 days) is a significant factor in considering the cause of her symptoms. Breast engorgement is
common during the first few days postpartum as milk production becomes established.
The nurse should assess the client's breastfeeding technique and ensure proper latching to prevent nipple trauma and
encourage effective milk removal.
Monitoring the client's temperature and other vital signs is crucial for identifying potential signs of infection, such as mastitis.
Providing the client with supportive measures such as comfortable bras and pain relief medications can also contribute to her
comfort and well-being.
By addressing the underlying cause of breast engorgement (milk build-up) through milk expression, the nurse can effectively
manage the client's symptoms and prevent potential complications like mastitis.
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