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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Subconjunctival hemorrhage is common after vaginal delivery and usually harmless.
B. Overlapping suture lines are normal in newborns due to molding during birth.
C. Nasal flaring is a sign of respiratory distress and requires immediate assessment.
D. Rust-stained urine can be due to urate crystals and is usually benign in newborns.
Correct Answer is ["B","E"]
Explanation
A. Maternal Rh factor – The mother is O positive. Rh incompatibility is not a concern here because both mother and newborn are likely Rh positive, and no information suggests Rh incompatibility.
B. Gestational age – The newborn was born at 36 weeks and 4 days, which is considered late preterm and places the infant at increased risk for complications such as respiratory distress, jaundice, hypoglycemia, and feeding difficulties.
C. Apgar scores – Scores of 7 at 1 minute and 8 at 5 minutes are within the normal range and not indicative of distress or a complication risk.
D. Weight – A birth weight of 3,062 g (6 lb 12 oz) is appropriate for gestational age and not a risk factor.
E. Type of birth – Operative vaginal birth using a vacuum extractor increases the risk for complications like cephalohematoma, which is noted in the assessment (firm, edematous scalp area with ecchymosis not crossing suture lines). This can contribute to jaundice.
F. Length – A length of 48 cm (19 in) is appropriate for gestational age and not a risk factor.
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