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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. Abdominal assessment – The abdomen is tender to palpation, which is an abnormal finding and can indicate uterine activity or irritation associated with preterm labor or other complications.
B. Low back pain – This is a common early sign of preterm labor, especially when combined with uterine cramping and cervical changes.
C. Uterine contractions – Although the client has cramping, there is no specific documentation of palpable or monitor-confirmed contractions, so this cannot be definitively selected based on available data.
D. Abdominal cramping – This is concerning in a pregnant client at 30 weeks, especially in combination with cervical dilation, vaginal bleeding, and back pain.
E. Fundal height – At 30 weeks, a fundal height of 28 cm is within the normal range (should match gestational age ±2 cm). This is not abnormal.
F. Fetal heart rate – The scenario notes positive fetal movement but does not mention an abnormal FHR. Without abnormal FHR data, this cannot be selected.
Correct Answer is D
Explanation
A. Monitoring cervical dilation is important but not the immediate priority.
B. Asking about the color of the amniotic fluid helps assess for meconium but is secondary.
C. Vaginal pH testing can help confirm rupture but is not the first action.
D. Determining the fetal heart rate is the priority to assess for signs of fetal distress immediately after rupture of membranes.
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