A nurse is caring for a client in the second stage of labor.
The nurse observes retraction of the fetal head against the maternal perineum after the fetal head is birthed.
What potential condition could the client be experiencing, what parameters should the nurse monitor to assess the client’s progress, and what actions should the nurse take?
The Correct Answer is ["-"]
The nurse is observing a potential case of shoulder dystocia, a condition where the baby’s head has been delivered but one of the shoulders becomes stuck behind the mother’s pelvic bone. The nurse should monitor the mother’s vital signs and the baby’s heart rate. The nurse should call for immediate assistance, perform maneuvers to help deliver the baby, and prepare for a potential emergency cesarean section if necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Repaglinide is an oral medication used to control blood sugar levels in adults with type 2 diabetes. It is not typically used in pregnant women, especially those unable to control their gestational diabetes with diet and exercise.
Choice B rationale
Insulin is the most common medication used to control blood sugar levels in pregnant women, especially those unable to control their gestational diabetes with diet and exercise.
Choice C rationale
Glipizide is an oral medication used to control blood sugar levels in adults with type 2 diabetes. It is not typically used in pregnant women, especially those unable to control their gestational diabetes with diet and exercise.
Choice D rationale
Acarbose is an oral medication used to control blood sugar levels in adults with type 2
diabetes. It is not typically used in pregnant women, especially those unable to control their gestational diabetes with diet and exercise.
Correct Answer is ["D"]
Explanation
A blood pressure of 179/99 mm Hg in a pregnant client is a cause for concern and should be reported to the provider. This could be a sign of preeclampsia, a serious condition that can occur during pregnancy characterized by high blood pressure and damage to other organ systems, most often the liver and kidneys. The other vital signs (temperature, pulse rate, and respiratory rate) are within normal ranges for a pregnant woman.
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