A nurse is performing Leopold maneuvers on a client who is in labor and determines the fetus is in an RSA position. Which of the following fetal presentations should the nurse document in the client's medical record?
Shoulder
Breech
Vertex
Mentum
The Correct Answer is B
A. Shoulder presentation is not typically described using the terms RSA. Shoulder presentation would be noted differently, and it is uncommon.
B. Breech presentation involves the presentation of the fetus with the buttocks or feet first. RSA indicates the specific position of the sacrum in relation to the mother's right side.
C. Vertex presentation refers to the head-first position, and it is not described using the terms RSA.
D. Mentum presentation is not a standard term used to describe fetal presentation. Mentum typically refers to the chin, and fetal presentations are commonly described in terms of the presenting part (e.g., vertex, breech).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Bilirubin 9 mg/dL is correct. A bilirubin level of 9 mg/dL in a newborn, especially at 4 hours old, is elevated and needs prompt attention. High bilirubin levels in newborns can be indicative of jaundice, and severe jaundice may lead to complications such as kernicterus. Monitoring and managing bilirubin levels are crucial to prevent potential neurologic damage.
Choice B Reason:
Hemoglobin 15 g/dL is incorrect. This hemoglobin level is within the normal range for a newborn. It's important to note that newborns often have higher hemoglobin levels shortly after birth, and this value is consistent with normal physiological ranges.
Choice C Reason:
Platelets 175,000/mm³ is incorrect. A platelet count of 175,000/mm³ is within the normal range for a newborn. There is no immediate concern based on this platelet count.
Choice D Reason:
Hematocrit 45% is incorrect. A hematocrit level of 45% is within the normal range for a newborn. Like hemoglobin, hematocrit levels can be higher in newborns shortly after birth, and this value falls within the expected range.
Correct Answer is C
Explanation
A. Instructing the client to increase her respiratory rate to more than 42 breaths per minute may exacerbate hyperventilation and cause respiratory alkalosis. This is not the appropriate action in this situation.
B. Breathing into a paper bag is an outdated and potentially dangerous practice. It can lead to a buildup of carbon dioxide in the body and may have adverse effects on both the mother and the baby. It is not recommended.
C. Having the client tuck her chin to her chest is the correct action.
This maneuver helps decrease the respiratory rate and prevent hyperventilation. It promotes a controlled and appropriate breathing pattern during labor.
D. Administering oxygen via nasal cannula is not the first-line intervention for lightheadedness and tingling during labor. The client's symptoms are likely due to hyperventilation, and addressing the breathing pattern is more appropriate.
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