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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Abdominal pain accompanied by minimal red vaginal bleeding is not a typical symptom of placenta previa. In placenta previa, the placenta covers all or part of the cervix, which can cause severe bleeding. However, this bleeding is typically not associated with abdominal pain.
Choice B rationale
Intermittent abdominal pain following the passage of bloody mucus is not a common symptom of placenta previa. This symptom is more commonly associated with labor or other conditions, but not specifically with placenta previa.
Choice C rationale
Increasing abdominal pain with a nonrelaxed uterus is not a typical symptom of placenta previa. This could be a sign of other complications such as uterine rupture or placental abruption, which are serious conditions that require immediate medical attention.
Choice D rationale
Painless red vaginal bleeding is indeed a symptom of placenta previa. This bleeding is usually bright red and can occur intermittently or continuously. It is most common in the third trimester of pregnancy.
Correct Answer is A
Explanation
Step 1 is to calculate the volume of Toradol to be drawn up. Toradol is available in 60 mg/mL. Therefore, to administer a dose of 30 mg, the nurse would need to draw up 30 mg ÷ 60 mg/mL = 0.5 mL.
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