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 A
Explanation
Choice A rationale
The symptoms described, including the paradoxical movement of the chest wall (moving inward during inspiration and outward during expiration), are indicative of a flail chest, which is a life-threatening condition that occurs when a segment of the rib cage breaks due to trauma and becomes detached from the rest of the chest wall.
Choice B rationale
Hemothorax is a collection of blood in the space between the chest wall and the lung (the pleural cavity). It’s often caused by chest trauma. It does not cause the chest to move inward during inspiration and outward during expiration.
Choice C rationale
Atelectasis is a complete or partial collapse of the entire lung or area (lobe) of the lung. It does not cause the chest to move inward during inspiration and outward during expiration.
Choice D rationale
Pneumothorax is a collapsed lung. It does not cause the chest to move inward during inspiration and outward during expiration.
Correct Answer is B
Explanation
The priority nursing action for a patient in labor with an epidural anesthesia block and a blood pressure of 80/40 mm Hg is to place the patient in a lateral position. This can help improve maternal blood flow and fetal oxygenation.
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