The nurse in the antepartum unit is caring for a 38-year-old client admitted for complications.

Based on the assessment and laboratory findings in the electronic health record, which priority interventions should the nurse consider.

This clinical scenario describes shoulder dystocia indicated by the turtle sign. Management requires immediate obstetric maneuvers to resolve the obstruction. Knowledge of emergency protocols, including McRoberts maneuver and suprapubic pressure, is essential to prevent fetal asphyxia and maternal trauma during delivery.

Choice A rationale

Fundal pressure is strictly contraindicated in cases of shoulder dystocia because it can further impact the anterior fetal shoulder against the maternal symphysis pubis. This action increases the risk of uterine rupture and severe brachial plexus injury.

Choice B rationale

Suprapubic pressure helps dislodge the impacted anterior shoulder by pushing it under the maternal symphysis pubis. This manual maneuver decreases the fetal bisacromial diameter, allowing the shoulder to rotate and pass through the pelvic outlet during the delivery.

Choice C rationale

Flexing the thighs toward the ears, known as the McRoberts maneuver, flattens the sacral promontory and increases the pelvic inlet diameter. This postural change facilitates the passage of the fetal shoulder and is often the first-line intervention.

Choice D rationale

Shoulder dystocia is a high-risk obstetric emergency that necessitates a multidisciplinary team approach. Calling for help ensures that neonatal resuscitation teams, anesthesia, and additional nursing staff are available to assist with complex maneuvers and provide immediate care.

Choice E rationale

While a cesarean birth is a major surgical procedure, it is typically not the immediate step once the head is delivered. Rescuers first attempt maneuvers to deliver the body vaginally, as reversing the delivery process is extremely difficult and dangerous.

Assessing fetal well-being through fundal height measurement requires knowledge of gestational benchmarks and anatomical landmarks. The nurse must apply the McDonald technique, measuring from the symphysis pubis to the top of the uterus, to evaluate appropriate growth patterns during pregnancy.

Choice A rationale

Fundal height measurement is a non-invasive, external procedure using a tape measure. It involves palpating the abdomen to find the uterine fundus and does not require internal examination or high-risk maneuvers, making this statement clinically inaccurate and misleading.

Choice B rationale

Fundal height is a standard screening tool used from 20 weeks until term to evaluate fetal growth. Between 20 and 36 weeks, the measurement in centimeters generally correlates with the gestational age in weeks, within a range.

Choice C rationale

The correct measurement starts at the symphysis pubis and extends to the top of the fundus. Measuring from the umbilicus is incorrect, as the umbilicus is only a landmark for approximately 20 weeks of gestation, not the base.

Choice D rationale

Fundal height is performed at every prenatal visit after 20 weeks to monitor consistent growth trends. A single measurement provides a baseline but cannot track the serial progression necessary to identify intrauterine growth restriction or macrosomia over time..