The baby's head is delivered at 0900. The shoulders are not delivered and you notice a turtle sign. Interventions to relieve a dystocia include (Select all that apply):
Enter maneuvers (wood screw or rubin) by physician
Put mother on all fours (gaskin)
Suprapubic pressure by the nurse
McRoberts by the nurse
Delivery of the anterior arm by the physician
Fundal pressure by the nurse
Correct Answer : A,B,C,D,E
Choice A: Enter maneuvers (wood screw or rubin) by physician are interventions to relieve a dystocia, as they involve rotating the fetal shoulders to align them with the maternal pelvis and facilitate the delivery. The physician can perform these maneuvers by applying pressure on the fetal clavicles or scapulas through the vaginA.
Choice B: Put mother on all fours (gaskin) is an intervention to relieve a dystocia, as it involves changing the maternal position to widen the pelvic outlet and reduce the pressure on the fetal shoulders. The mother can assume this position by kneeling on the bed and resting on her elbows or hands.
Choice C: Suprapubic pressure by the nurse is an intervention to relieve a dystocia, as it involves applying firm and downward pressure on the mother's lower abdomen to dislodge the anterior fetal shoulder from behind the pubic symphysis and assist the delivery. The nurse can perform this intervention by using the heel of the hand or a fist.
Choice D: McRoberts by the nurse is an intervention to relieve a dystocia, as it involves flexing and abducting the mother's legs to her chest to increase the pelvic diameter and relax the pelvic floor muscles. The nurse can perform this intervention by holding the mother's legs or using stirrups.
Choice E: Delivery of the anterior arm by the physician is an intervention to relieve a dystocia, as it involves reaching into the vagina and sweeping the fetal arm across the chest and out of the birth canal to reduce the shoulder-to-shoulder diameter and assist the delivery. The physician can perform this intervention by using a finger or a forceps.
Choice F: Fundal pressure by the nurse is not an intervention to relieve a dystocia, as it involves pushing on the upper part of the uterus to expel the fetus. This intervention is contraindicated in shoulder dystocia, as it can worsen the impaction of the fetal shoulders and cause fetal injury or maternal traumA.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Correct Answer is A
Explanation
Choice B. Report the client's temperature elevation is incorrect. The client's temperature is within the normal range for a postpartum woman, which can be slightly elevated due to dehydration, increased metabolism, or breast engorgement. A fever of 38°C (100.4°F. or higher could indicate an infection and should be reporteD.
Choice C. Increase IV fluids is incorrect. The client does not have signs of hypovolemia or dehydration that would require increased IV fluids. Excessive fluid administration can cause fluid overload and pulmonary edema in postpartum women.
Choice D. Encourage the client to nurse more frequently so her milk will come in is incorrect. The client's breasts are soft, which indicates that her milk has not come in yet. Nursing more frequently will stimulate milk production, but it will not help with the current problem of uterine atony and hemorrhagE. The nurse should massage the fundus and administer oxytocin as prescribed to enhance uterine contraction.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.