A nurse is caring for a client who has been in labor for 12 hours with intact membranes. The nurse performs a vaginal examination to ensure which of the following prior to the performance of the amniotomy?
Fetal position
Fetal lie
Fetal attitude
fetal engagement
The Correct Answer is D
The correct answer is D. Fetal engagement
A. Fetal position, fetal lie, and fetal attitude are important aspects of the fetal presentation but are not specific considerations when performing an amniotomy.
B. Fetal lie is the relationship between the long axis of the fetus and the long axis of the mother. It is not directly relevant to the consideration of amniotomy.
C. Fetal attitude refers to the relationship of the fetal body parts to each other. It is not a specific consideration for amniotomy.
D. Fetal engagement is the correct consideration prior to amniotomy.
Fetal engagement refers to the descent of the fetal presenting part into the pelvis. Before performing an amniotomy, it is important to confirm that the fetal head is engaged in the pelvis, ensuring a lower risk of cord prolapse.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D.
A. Slowing the client's rate of breathing is not directly related to the observed uniform decelerations. The primary concern is the fetal heart rate pattern.
B. Decreasing the rate of infusion of the maintenance IV solution is not the appropriate intervention for addressing the observed fetal heart rate decelerations. The focus should be on the oxytocin infusion rate.
C. Increasing the rate of infusion of the IV oxytocin is not the appropriate action.
The patient is already experiencing frequent and strong contractions, and increasing the oxytocin rate can exacerbate the decelerations and compromise fetal well-being.
D. Discontinuing the infusion of the IV oxytocin is the correct action.
The observed uniform decelerations are likely related to oxytocin-induced hyperstimulation of the uterus. Stopping or decreasing the oxytocin infusion allows for the uterine activity to decrease, potentially improving fetal heart rate patterns.
Correct Answer is A
Explanation
Choice A Reason:
Applying sacral counterpressure is appropriate. In the right occiput posterior position, the fetal head is positioned towards the mother's back, leading to increased pressure on the sacral are
A. Applying sacral counterpressure can help alleviate back pain during contractions.
Choice B Reason:
Performing transcutaneous electrical nerve stimulation (TENS) is inappropriate. While TENS can be used for pain relief in labor, applying sacral counterpressure is a more specific intervention for back pain related to fetal positioning.
Choice C Reason:
Initiating slow-paced breathing is inappropriate. While slow-paced breathing is a coping mechanism during contractions, it may not specifically address the back pain associated with the fetus in the right occiput posterior position.
Choice D Reason:
Assisting with biofeedback is inappropriate. Biofeedback is not a standard intervention for managing back pain during labor, especially in the context of fetal positioning. Sacral counterpressure is a more direct approach for this situation.
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