When assisting with a vacuum-assisted vaginal delivery, the nurse is aware that adherence to which guidelines for the vacuum device will minimize the nurse's liability in vacuum-assisted vaginal births? Select all that apply.

Pump up the vacuum manually to the pressure indicated on the pump.

Recognize that cup detachment (pop off) is a warning sign.

The cup should not be on the fetal head for longer than 5 to 10 minutes.

The procedure is timed from insertion of the cup into the vagina until the birth.

Understand that pressure should be released between contractions.

Answer and Explanation

Correct Answer : B,C,E

Choice A rationale

Pumping up the vacuum manually to the pressure indicated on the pump is a standard procedure but doesn't directly minimize liability.

Choice B rationale

Recognizing cup detachment (pop off) as a warning sign is critical, as it indicates excessive force or poor positioning, which can lead to fetal or maternal injury.

Choice C rationale

Limiting the cup's attachment to the fetal head to 5 to 10 minutes reduces the risk of scalp injury and other complications, thus minimizing liability.

Choice D rationale

Timing the procedure from insertion of the cup into the vagina until the birth is a guideline but doesn't specifically address liability concerns.

Choice E rationale

Releasing pressure between contractions prevents continuous suction on the fetal head, reducing the risk of injury and thereby minimizing liability.

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Correct Answer is D

Explanation

Choice A rationale

Placental abruption involves the detachment of the placenta from the uterine wall before delivery, causing bleeding, abdominal pain, and uterine tenderness. It does not typically cause dyspnea, hypotension, frothy sputum, or loss of consciousness.

Choice B rationale

Uterine rupture is a tear in the uterine wall, often in a scarred uterus. Symptoms include severe abdominal pain, abnormal fetal heart rate, and vaginal bleeding. It can cause shock, but not frothy sputum or sudden dyspnea.

Choice C rationale

Uterine inversion occurs when the uterus turns inside out, often during placental delivery. It leads to pain, hemorrhage, and shock. Like uterine rupture, it does not cause frothy sputum or sudden dyspnea.

Choice D rationale

Anaphylactoid syndrome (amniotic fluid embolism) occurs when amniotic fluid enters the maternal circulation, causing an anaphylactic reaction. Symptoms include sudden dyspnea, hypotension, frothy sputum, and loss of consciousness, fitting the scenario described.

A. Check the blood sugar of a gestational diabetic. B. Assess the vaginal blood loss of a client who is recovering from a spontaneous abortion. C. Assess the patellar reflexes of a client with pre-eclampsia without severe features. D. Check the fetal heart rate of a client whose membranes just ruptured.

Correct Answer is D

Explanation

Choice A rationale

Checking the blood sugar of a gestational diabetic is essential but not immediately life-threatening. Blood sugar levels should be monitored regularly throughout pregnancy for diabetics to prevent complications. However, this does not represent an urgent priority when compared to the other options, which involve more immediate risks to life and health.

Choice B rationale

Assessing vaginal blood loss in a client recovering from a spontaneous abortion is crucial to monitor for hemorrhage or infection. Heavy bleeding could signal a serious complication needing immediate intervention, though it is not the most immediate priority over monitoring fetal heart rate during active labor.

Choice C rationale

Monitoring the patellar reflexes of a client with pre-eclampsia without severe features can help in detecting early signs of progressing pre-eclampsia. While important, it is generally not as critical as ensuring immediate fetal wellbeing, especially if reflexes do not present signs of worsening.

Choice D rationale

Checking the fetal heart rate in a client whose membranes have just ruptured is paramount. Rupture of membranes could lead to immediate complications such as umbilical cord prolapse, leading to rapid fetal distress. Therefore, verifying fetal heart rate ensures that the fetus is not in immediate danger.

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When assisting with a vacuum-assisted vaginal delivery, the nurse is aware that adherence to which guidelines for the vacuum device will minimize the nurse's liability in vacuum-assisted vaginal births? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is D

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