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.

Discontinue fetal monitoring during the procedure.

Encourage the client to push during contractions.

Administer a fluid bolus to ensure a full bladder during the procedure.

Answer and Explanation

The Correct Answer is C

A. The vacuum cup is positioned on the fetal head, over the flexion point, not in front of the ears.
B. Continuous fetal monitoring should be maintained during vacuum-assisted delivery.
C. The nurse should encourage the client to push during contractions to assist with the delivery.
D. A full bladder can obstruct delivery; the bladder should be emptied prior to the procedure.

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Correct Answer is B

Explanation

A. A grade 2 placental abruption typically presents with a firm or rigid abdomen due to concealed bleeding, not a soft one.
B. Maternal tachycardia (heart rate 120/min) is expected due to blood loss and compensatory response to hypovolemia.
C. A fetal heart rate of 150/min with moderate variability is a reassuring sign and would not typically be expected in a significant abruption, where fetal distress is more common.
D. Vaginal bleeding from placental abruption is typically painful, and may be concealed. Painless bleeding is more characteristic of placenta previa.

A. Instruct the mother to delay breastfeeding for 1 week. B. Initiate airborne precautions. C. Wait at least 24 hr before bathing the newborn. D. Administer hepatitis B immune globulin IM to the newborn.

Correct Answer is D

Explanation

A. Breastfeeding is not contraindicated in mothers with hepatitis B if the newborn receives appropriate prophylaxis.
B. Airborne precautions are not necessary; hepatitis B is transmitted through blood and body fluids, not airborne droplets.
C. Bathing the newborn does not affect hepatitis B transmission risk and does not need to be delayed.
D. Administering hepatitis B immune globulin (HBIG) IM to the newborn within 12 hours of birth, along with the first dose of the hepatitis B vaccine, is essential to prevent vertical transmission of hepatitis B virus.

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A nurse is caring for a client who is having a vacuum-assisted birth. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a grade 2 placental abruption. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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