A nurse is caring for a client who is having a vacuum-assisted birth.
Which of the following actions should the nurse take?
Inform the client that the vacuum cup will be positioned in front of the fetal ears.
Encourage the client to push during contractions.
Discontinue fetal monitoring during the procedure.
Administer a fluid bolus to ensure a full bladder during the procedure.
The Correct Answer is B
Choice A rationale
The vacuum cup for an assisted birth is strategically placed on the fetal occiput, which is the posterior aspect of the fetal skull, not in front of the fetal ears. Proper placement over the posterior fontanelle promotes traction directly on the bone, minimizing the risk of fetal scalp injury and ensuring efficient rotation and descent of the fetal head during traction. Positioning near the ears is incorrect and dangerous.
Choice B rationale
During a vacuum-assisted birth, the client is actively encouraged to push effectively with each uterine contraction, as the vacuum traction is applied only during a contraction. Maternal pushing augments the force of the vacuum device and facilitates the fetal head's descent through the birth canal, maximizing the procedure's success while minimizing the duration and number of pulls required for delivery.
Choice C rationale
Continuous fetal monitoring is absolutely essential throughout a vacuum-assisted birth procedure. It allows the nurse and provider to immediately assess the fetal heart rate (FHR) response to the procedure, identify potential complications like bradycardia or non-reassuring FHR patterns, and guide the discontinuation of the vacuum if fetal compromise is detected.
Choice D rationale
Administering a fluid bolus to ensure a full bladder is contraindicated during labor and birth. An empty bladder is preferred for fetal descent and to prevent obstruction of the birth canal. Furthermore, a full bladder can potentially be damaged by the descending fetal head, making bladder emptying (catheterization) common prior to assisted delivery if necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A nonreactive nonstress test (NST), defined by having fewer than two accelerations of at least 15 beats per minute (BPM) above baseline, lasting at least 15 seconds, within a 20-minute window, indicates potential fetal compromise or sleep state, leading to a maximum score of 0 on this component, thus not indicating well-being.
Choice B rationale
The biophysical profile (BPP) scores fetal movement with a maximum of 2 points for three or more discrete body or limb movements within a 30-minute period. The finding of four limb movements clearly meets this criterion and earns the full 2 points, reflecting an intact central nervous system and adequate fetal oxygenation, which is a sign of fetal well-being.
Choice C rationale
The BPP criterion for fetal breathing movements requires at least one episode of sustained movements for 30 seconds within the 30-minute observation period to score 2 points. The finding of 20 seconds is insufficient to meet this 30-second threshold, resulting in a score of 0 points for this component and thus not indicating full well-being.
Choice D rationale
The amniotic fluid index (AFI) measures the sum of the deepest vertical pockets of amniotic fluid in the four quadrants of the uterus. An AFI of 1 cm is significantly below the normal range of 5 cm to 25 cm, indicating oligohydramnios (low fluid). This finding scores 0 points on the BPP and suggests potential chronic fetal compromise or renal issues.
Correct Answer is C
Explanation
Choice A rationale
Hemorrhagic shock results from significant blood loss, leading to decreased circulating blood volume and subsequent hypotension. Therefore, hypertension is not expected; instead, the nurse should anticipate hypotension as a classic sign, indicating the body's compensatory mechanisms are failing to maintain adequate perfusion. Systolic blood pressure below 90 mmHg is a common indicator of shock.
Choice B rationale
Initial compensatory mechanisms in shock, driven by the sympathetic nervous system, usually include tachypnea (increased respiratory rate) to enhance oxygenation and address resulting metabolic acidosis. Bradypnea (abnormally slow respiratory rate, normal 12-20 breaths/min) is a late and ominous sign, reflecting profound central nervous system depression and circulatory failure.
Choice C rationale
Tachycardia (heart rate >100 beats/min) is an early and compensatory sign of hemorrhagic shock, triggered by the release of catecholamines (epinephrine, norepinephrine). The sympathetic nervous system increases the heart rate and contractility to compensate for the reduced stroke volume caused by the hypovolemia and maintain cardiac output and tissue perfusion.
Choice D rationale
Hemorrhagic shock causes a severe reduction in renal blood flow due to vasoconstriction and low systemic pressure. This results in oliguria (urine output <30 mL/hr) or anuria, not polyuria. Decreased urine output is a critical indicator of inadequate perfusion to the kidneys and is a classic finding in progressing shock.
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