A nurse is caring for a client who is in the second stage of labor and is experiencing a shoulder dystocia.
The provider instructs the nurse to perform the McRoberts maneuver.
Which of the following actions should the nurse take?
Assist the client in pulling their knees toward their abdomen.
Press firmly on the client's suprapubic area.
Move the client onto their hands and knees.
Apply pressure to the client's fundus.
The Correct Answer is A
Choice A rationale:
The McRoberts maneuver involves an obstetrician or other healthcare provider flexing the thighs of a pregnant person toward their abdomen. This maneuver helps to rotate the pelvis and open the sacrum to release the baby’s shoulder.
Choice B rationale:
Applying pressure on the client’s suprapubic area is not part of the McRoberts maneuver. However, when coupled with suprapubic pressure, the effectiveness of the McRoberts maneuver increases to 90%1.
Choice C rationale:
Moving the client onto their hands and knees is not part of the McRoberts maneuver. The maneuver involves pressing the client’s legs against their abdomen.
Choice D rationale:
Applying pressure to the client’s fundus is not part of the McRoberts maneuver. The maneuver involves pressing the client’s legs against their abdomen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Hypertension is not a typical symptom of abruptio placentae.
Choice B rationale:
Uterine tenderness is a common symptom of abruptio placentae.
Choice C rationale:
Fetal tachycardia is not a typical symptom of abruptio placentae.
Choice D rationale:
Leukorrhea is not associated with abruptio placentae.
The most likely finding the nurse should expect in a client experiencing abruptio placenta during labor is:
b. Uterine tenderness.
Here's why:
- Hypertension (a):While preeclampsia can increase the risk of abruptio placenta,it's not always present,and hypertension wouldn't be the immediate expected finding during the abruption event itself.
- Fetal tachycardia (c):This can occur in early stages of abruption to compensate for decreased oxygen supply,but as the abruption becomes more severe,fetal bradycardia is more likely due to oxygen deprivation.
- Leukorrhea (d):This is a white vaginal discharge and has no connection to abruptio placenta.
Uterine tenderness is a characteristic sign of abruptio placenta due to bleeding behind the placenta and irritation of the uterine muscle. This is often accompanied by:
- Vaginal bleeding (bright red or dark)
- Abdominal pain or cramping
- Sudden, ongoing uterine tightening or irritability
- Fetal distress (decreased fetal heart rate movements)
Therefore, option b is the most expected finding in this scenario.
Remember: Early recognition and prompt management of abruptio placenta are crucial for optimal outcomes for both mother and baby. If you suspect abruptio placenta, immediate medical attention is essential.
Correct Answer is A
Explanation
Choice A rationale:
Yellowed sclera in a newborn could indicate jaundice, which should be reported to the provider.
Choice B rationale:
Stooling after each breastfeeding is normal for a newborn.
Choice C rationale:
Intermittent crossing of eyes is common in newborns and usually resolves by 3 months of age.
Choice D rationale:
Voiding eight to ten times per day is normal for a newborn.
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