A nurse is performing Leopold maneuvers on a patient in labor and determines the fetus is in an RSA position. What fetal presentations should the nurse document in the patient’s medical record?
Shoulder
Vertex
Mentum
Breech
The Correct Answer is D
Choice A rationale
The shoulder is not the correct fetal presentation in this case. The shoulder presentation, also known as a transverse lie, occurs when the fetus is positioned horizontally in the uterus, and the shoulder is the presenting part. This is not the case in an RSA (Right Sacrum Anterior) position, which indicates a breech presentation.
Choice B rationale
The vertex presentation, also known as a cephalic presentation, occurs when the fetus is positioned head down in the uterus. However, in an RSA position, the fetus is in a breech presentation, not a vertex presentation.
Choice C rationale
The mentum (face) presentation is a rare type of fetal presentation where the neck of the fetus is hyperextended, and the face presents at the cervix. This is not the case in an RSA position, which indicates a breech presentation.
Choice D rationale
In an RSA (Right Sacrum Anterior) position, the fetus is in a breech presentation. This means that the buttocks or feet of the fetus are positioned to enter the birth canal first. Therefore, the nurse should document a breech presentation in the patient’s medical record.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Nitroglycerin oral, sustained-release capsules are not typically taken at the onset of anginal pain. They are usually used to prevent angina attacks rather than to treat them.
Choice B rationale
There is no specific requirement to take the medication with meals.
Choice C rationale
While side effects can be troublesome, patients should not stop taking the medication without consulting their healthcare provider.
Choice D rationale
Nitroglycerin oral, sustained-release capsules should be swallowed whole. They should not be crushed or chewed.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
While monitoring abdominal girth can be important in patients with cirrhosis, especially those with ascites, it is not typically an assessment finding that requires immediate follow-up.
Choice B rationale
A blood pressure of 82/58 mm Hg is low and could indicate hypotension, which requires immediate follow-up.
Choice C rationale
A heart rate of 101/min is elevated and could indicate tachycardia, which requires immediate follow-up.
Choice D rationale
An oxygen saturation of 92% is lower than the normal range of 95% to 100%, indicating potential hypoxia, which requires immediate follow-up.
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