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?
Encourage the mother to push during the next contraction.
Prepare for immediate delivery of the baby.
Call for additional medical support.
Administer pain relief medication.
The Correct Answer is C
Choice A rationale:
Encouraging the mother to push during the next contraction is not the appropriate action in this situation. Retraction of the
fetal head against the maternal perineum is a sign of shoulder dystocia, a serious obstetric emergency that requires immediate
intervention. Pushing could potentially worsen the situation by further impacting the anterior shoulder against the maternal
pubic symphysis.
Choice B rationale:
While preparing for immediate delivery of the baby may be necessary in some cases of shoulder dystocia, it is not the first
priority. The initial focus should be on relieving the impaction of the anterior shoulder and facilitating the safe delivery of the
baby. This often requires additional maneuvers and medical support.
Choice C rationale:
Calling for additional medical support is the most appropriate action in this situation. Shoulder dystocia can be a complex and
challenging emergency, and it's crucial to have experienced healthcare providers available to assist with the delivery.
Additional personnel can provide support with various maneuvers, fetal monitoring, and management of potential
complications.
Choice D rationale:
Administering pain relief medication is not a priority in this situation. While pain management is important during labor, it
should not take precedence over addressing the immediate obstetric emergency. The focus should be on resolving the
shoulder dystocia and ensuring a safe delivery.
Additional notes:
It's important to note that shoulder dystocia is a relatively uncommon complication, occurring in approximately 0.5-1% of all
vaginal births. However, it's a potentially serious emergency that can lead to significant complications for both the mother and
baby, such as brachial plexus injury, hypoxic-ischemic encephalopathy, and postpartum hemorrhage.
Early recognition and prompt intervention are crucial for optimizing outcomes in cases of shoulder dystocia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale: A fundus that is firm and 4 fingerbreadths above the umbilicus 24 hours postpartum indicates uterine atony or retained placental fragments. This finding is not typical and may require further medical evaluation to prevent postpartum hemorrhage.
Choice B rationale: A soft fundus 2 fingerbreadths below the umbilicus suggests uterine atony, which can lead to postpartum hemorrhage. Uterine atony is a condition where the uterus fails to contract effectively after childbirth.
Choice C rationale: A soft fundus to the right of the umbilicus may indicate a full bladder pushing the uterus to one side. It can interfere with uterine contractions and should be addressed by encouraging the client to empty their bladder.
Choice D rationale: A firm fundus at 1 fingerbreadth below the umbilicus is the expected finding 24 hours postpartum. It indicates that the uterus is contracting well and returning to its pre-pregnancy size, reducing the risk of postpartum hemorrhage.
Correct Answer is B
Explanation
Choice A rationale:
Placing a soft pillow under the client's buttocks is not recommended for episiotomy pain relief. It can actually increase pain by placing pressure on the perineum and impeding blood flow to the area. This can hinder healing and prolong discomfort.
Additionally, it can separate the buttocks, potentially decreasing venous return and further exacerbating pain.
Choice C rationale:
Positioning a heating lamp toward the episiotomy is not appropriate within the first 24 hours following delivery. Heat application during this early stage can increase inflammation and swelling, potentially worsening pain and delaying healing.
Heat therapy is typically recommended after 24 hours to promote circulation and tissue repair, but it's crucial to apply it at the appropriate time.
Choice D rationale:
Preparing a warm sitz bath is a common comfort measure for postpartum perineal care, but it's generally recommended after
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