A nurse is caring for a client in the second stage of labor who is experiencing shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver.
What action should the nurse take?
Press firmly on the client’s suprapubic area.
Assist the client in pulling their knees toward their abdomen.
Apply pressure to the client’s fundus.
Move the client onto their hands and knees.
The Correct Answer is B
Choice A rationale
Applying firm pressure on the client’s suprapubic area is not part of the McRoberts maneuver. This action is more associated with the suprapubic pressure technique, which is another method used to manage shoulder dystocia.
Choice B rationale
The McRoberts maneuver involves having the client flex her hips against her abdomen. This is achieved by assisting the client in pulling her knees toward her abdomen.
Choice C rationale
Applying pressure to the client’s fundus is not part of the McRoberts maneuver and can be contraindicated as it may cause additional complications.
Choice D rationale
Moving the client onto their hands and knees is not part of the McRoberts maneuver. This position is more associated with the all-fours maneuver, also known as the Gaskin maneuver.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice d. Assist the client to the bathroom.
Choice A rationale:
Inserting a urinary catheter is an invasive procedure and should be considered only after less invasive measures have been attempted and failed. It carries risks such as infection and trauma to the urethra.
Choice B rationale:
Pouring warm water over the client’s perineum can help stimulate urination, but it should be tried after assisting the client to the bathroom. It is a non-invasive method but not the first action to take.
Choice C rationale:
Offering a sitz bath can also help with urination by relaxing the perineal muscles, but it is not the first action to take. It is more appropriate if the client is unable to void after trying to use the bathroom.
Choice D rationale:
Assisting the client to the bathroom is the least invasive and most straightforward initial action. It allows the client to attempt to void naturally, which is preferable before trying other interventions.
Correct Answer is C
Explanation
Choice A rationale
The use of an oil-based vaginal lubricant when inserting a diaphragm is not recommended. Oil- based lubricants can damage the material of the diaphragm, reducing its effectiveness as a contraceptive method.
Choice B rationale
Keeping the diaphragm in place for at least 4 hours after intercourse is a standard recommendation. However, it does not address the specific needs of a postpartum woman. After childbirth, the size and shape of a woman’s vagina can change, potentially affecting the fit of the diaphragm.
Choice C rationale
The provider should refit the client for a new diaphragm. After childbirth, the size and shape of a woman’s vagina can change, potentially affecting the fit of the diaphragm. A poorly fitting diaphragm may not provide effective contraception.
Choice D rationale
Storing the diaphragm in sterile water after each use is not a standard recommendation. The diaphragm should be cleaned with mild soap and water, dried, and stored in a cool, dry place.
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