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 A
Explanation
Choice A rationale
The correct transcription of two tenths of a milligram is 0.2 mg. This format avoids any potential confusion that could lead to a medication error.
Choice B rationale
While 0.20 mg is technically correct, it is not the preferred format. The trailing zero after the decimal point is unnecessary and could potentially lead to confusion.
Choice C rationale
20 mg is not correct. This is 100 times the intended dose of two tenths of a milligram, and could lead to a serious medication error.
Choice D rationale
2 mg is not correct. This is 10 times the intended dose of two tenths of a milligram, and could lead to a medication error.
Correct Answer is D
Explanation
If a patient in labor who has received an epidural anesthesia block has a blood pressure reading of 80/40 mm Hg, the nurse’s immediate course of action should be to position the patient laterally. This helps to maximize venous return and cardiac output, thereby improving maternal blood pressure and fetal perfusion.
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