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 D
Explanation
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G (Gravida): Total number of pregnancies → 4
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T (Term births): Delivered at 37 weeks or more → One (39 weeks) → T = 1
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P (Preterm births): Delivered between 20–36 weeks → Twins (34 weeks, 1 pregnancy) + One at 35 weeks = 2 preterm pregnancies → P = 2
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A (Abortions): Pregnancies ending before 20 weeks → 0
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L (Living children): One from term birth, two from twins, and one from the other preterm = 4 living children → L = 4
Correct Answer: D. G4 T1 P2 A0 L4
Correct Answer is B
Explanation
Cervical dilation is a key sign that a patient is in labor. As labor progresses, the cervix dilates to allow the baby to pass through the birth canal. Other signs of labor can include regular contractions, rupture of membranes (amniotic fluid present in the vaginal vault), and changes in vaginal discharge.
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