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?

Answer and Explanation

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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Correct Answer is D

Explanation

Choice A rationale
Hypomagnesemia, or low magnesium levels, is not typically a primary concern for newborns of mothers with diabetes mellitus. While it can occur, it is not the priority focus of care.
Choice B rationale
Hyperbilirubinemia, or high bilirubin levels, can lead to jaundice in newborns. However, it is not the primary concern in newborns of mothers with diabetes mellitus. These newborns are more at risk for hypoglycemia.
Choice C rationale
Hypocalcemia, or low calcium levels, can occur in newborns, but it is not the primary concern in newborns of mothers with diabetes mellitus. These newborns are more at risk for hypoglycemia.

A. Baseline BP 140/85, current BP 129/80 B. Baseline BP 110/70, current BP 145/85 C. Baseline BP 120/80, current BP 126/85 D. Baseline BP 110/60, current BP 120/63 .

Correct Answer is B

Explanation

Choice A rationale
A baseline BP of 140/85 mmHg is considered high, but a current BP of 129/80 mmHg is within the normal range. Therefore, this would not typically indicate a risk for pregnancy-induced hypertension.
Choice B rationale
A significant increase in blood pressure from a baseline of 110/70 mmHg to a current BP of 145/85 mmHg could indicate a risk for pregnancy-induced hypertension.
Choice C rationale
A slight increase in blood pressure from a baseline of 120/80 mmHg to a current BP of 126/85 mmHg would not typically indicate a risk for pregnancy-induced hypertension.
Choice D rationale
An increase in blood pressure from a baseline of 110/60 mmHg to a current BP of 120/63 mmHg would not typically indicate a risk for pregnancy-induced hypertension.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn who has macrosomia and whose mother has diabetes mellitus. Which of the following newborn complications should the nurse recognize as the priority focus of care?

Correct Answer is D

Explanation

Which blood pressure (BP) finding during the second trimester indicates a risk for pregnancy-induced hypertension?

Correct Answer is B

Explanation

A nurse is caring for a client who is scheduled for a maternal serum alpha-fetoprotein test at 15 weeks of gestation. Which of the following explanations about this test should the nurse provide to the client?

A nurse is admitting a patient with severe pre-eclampsia at 35 weeks of gestation and is reviewing the provider’s orders. Which of the following orders requires clarification?

A nurse in a provider’s office is caring for a client who is pregnant. Which of the following assessment findings should the nurse report to the provider? (Select all that apply)

A nurse is attending to a first-time pregnant woman who is at term. She is experiencing contractions but is unsure if she is in labor. Which of the following should the nurse identify as a labor sign?

A nurse is caring for a patient who is about to undergo a biophysical profile. The patient asks the nurse what aspects are evaluated during this test. Which of the following should the nurse include? (Select all that apply)

The nurse caring for the pregnant patient understands that which hormone is essential for maintaining pregnancy?