A nurse is caring for a client who is in the second stage of labor. The nurse observes retraction of the fetal head against the maternal perineum as the head is birthed.
Which condition is the client most likely experiencing?
Shoulder dystocia.
Breech presentation.
Placenta previa.
Uterine rupture.
The Correct Answer is A
The correct answer is A. Shoulder dystocia. Retraction of the fetal head against the maternal perineum as the head is birthed is a classic sign of shoulder dystocia. This is a birth complication where the baby’s shoulder gets stuck behind the mother’s pelvic bone during delivery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Answer and explanation
The correct answer is Choice D.
Choice A rationale
A respiratory rate of 16 breaths per minute is within the normal range for an adult, and would not typically be a cause for concern.
Choice B rationale
A Fetal Heart Rate (FHR) of 158 beats per minute is within the normal range (110-160 beats per minute) and would not typically be a cause for concern.
Choice C rationale
While a persistent headache can be a symptom of pre-eclampsia, it is not typically a reason to report to the healthcare provider when a patient is receiving magnesium sulfate to manage pre-eclampsia.
Choice D rationale
A urinary output of 40 mL in 2 hours is less than the normal range (at least 30 mL/hour). This could indicate kidney dysfunction, which is a serious complication of pre-eclampsia. Therefore, this observation should be reported to the healthcare provider.
Correct Answer is D
Explanation
A. In a cephalic (head-down) presentation, fetal heart tones are typically heard below the umbilicus.
B. A posterior position refers to the fetal back facing the mother's back, but it does not affect the heart tone location significantly.
C. A transverse lie would place the fetal heart tones at the lateral sides of the abdomen, not above the umbilicus.
D. In a frank breech position (buttocks presenting first), fetal heart tones are usually heard above the umbilicus, as the fetal head is positioned in the upper uterus.
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