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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale
This is the best response because it acknowledges the client’s question and refers her to a healthcare provider who can provide a comprehensive assessment and discuss the most appropriate contraceptive options for her specific situation.
Choice B rationale
While it’s important to understand a client’s sexual activity when discussing contraception, asking a minor about her sexual activity without a proper context or professional setting may be inappropriate and uncomfortable for the client.
Choice C rationale
This response may come off as judgmental or condescending. It’s crucial to provide a safe and non-judgmental environment when discussing sensitive topics like sexual health and contraception.
Choice D rationale
While barrier methods can be an effective form of contraception, it’s not appropriate to recommend a specific method without a thorough understanding of the client’s health history, lifestyle, and preferences.

A. A client who has missed a menstrual cycle and reports vaginal spotting. B. A client who is at 28 weeks of gestation and reports painless vaginal bleeding. C. A client who is at 38 weeks of gestation and reports symptoms of a cough and fever. D. A client who is at 14 weeks of gestation and reports experiencing nausea and vomiting.

Correct Answer is B

Explanation

Choice A rationale
Missing a menstrual cycle and reporting vaginal spotting could indicate early pregnancy or other non-emergency conditions. While this client should be evaluated, it is not the highest priority.
Choice B rationale
A client at 28 weeks of gestation reporting painless vaginal bleeding could be experiencing placenta previa or placental abruption, both of which are obstetric emergencies. This client should be prioritized for immediate evaluation.
Choice C rationale
A client at 38 weeks of gestation reporting symptoms of a cough and fever may have an upper respiratory infection. While this should be evaluated, it is not the highest priority unless the client is in distress.
Choice D rationale
Nausea and vomiting are common in early pregnancy. A client at 14 weeks of gestation reporting these symptoms would need evaluation, but it is not the highest priority.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is leading a discussion about contraception with a group of 14-year-old clients. After the presentation, a client asks the nurse which method would be best for her to use. Which of the following responses should the nurse make?

Correct Answer is A

Explanation

As a nurse in an antepartum unit performing triage, which client should be prioritized?

Correct Answer is B

Explanation

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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?