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:
Elastic bandages can contain latex, which could potentially cause an allergic reaction. However, latex-free alternatives are available. The client should be advised to specifically look for latex-free bandages. This statement indicates a need for further teaching because using standard elastic bandages might expose the client to latex.
Choice B rationale:
Many dishwashing gloves are made from latex, but there are latex-free alternatives available. The client should be instructed to use latex-free gloves to avoid latex exposure. This statement indicates a need for further teaching as the client might choose latex gloves unintentionally.
Choice C rationale:
Most ink pens do not contain latex. Therefore, using ink pens is generally safe for individuals with latex allergies. This statement does not indicate a need for further teaching.
Choice D rationale:
Balloon latex is a common allergen, and exposure to latex balloons can trigger an allergic reaction in individuals with latex allergies. This statement indicates a need for further teaching because the client should avoid latex balloons and opt for latex-free alternatives to prevent allergic reactions.
Correct Answer is ["120"]
Explanation
The correct answer is 120 gtt/min.
Step 1 is to convert the infusion rate from mL/hr to mL/min: 120 mL/hr ÷ 60 min/hr = 2 mL/min.
Step 2 is to multiply the mL/min rate by the drop factor to find the gtt/min rate: 2 mL/min × 60 gtt/mL = 120 gtt/min.
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