A woman is in the second stage of labor where the fetal head has just been born and the nurse observes the immediate retraction of the head against the perineum.
What action should the nurse expect to perform to assist the healthcare provider?
Prepare a vacuum.
Apply suprapubic pressure.
Apply fundal pressure.
Prepare forceps.
Prepare forceps.
The Correct Answer is B
Choice A rationale
Preparing a vacuum is not the first action to take in this situation. A vacuum-assisted delivery might be considered in some cases, but it’s not the immediate action when the fetal head retracts against the perineum.
Choice B rationale
Applying suprapubic pressure is the correct action. This situation describes shoulder dystocia, where the baby’s shoulder gets stuck behind the mother’s pelvic bone during delivery. Suprapubic pressure can help dislodge the baby’s shoulder and allow the delivery to proceed.
Choice C rationale
Applying fundal pressure is not recommended in this situation. Fundal pressure could potentially worsen shoulder dystocia and is generally avoided.
Choice D rationale
Preparing forceps is not the immediate action to take. Forceps may be used in some delivery situations, but in the case of shoulder dystocia, other maneuvers are tried first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.72"]
Explanation
Step 1 is to calculate the total amount of oxytocin in the IV bag. This is done by multiplying the total volume of the bag by the concentration of oxytocin. In this case, the bag contains 5 units of oxytocin in 500 mL, so the concentration is 5 units ÷ 500 mL = 0.01 units/mL.
Step 2 is to convert the prescribed dose from milliunits/min to units/hour. There are 1000 milliunits in a unit and 60 minutes in an hour, so 12 milliunits/min = 12 ÷ 1000 units/min = 0.012 units/min. Then, 0.012 units/min × 60 min/hour = 0.72 units/hour.
Step 3 is to calculate the infusion rate in mL/hour. This is done by dividing the prescribed dose in units/hour by the concentration of oxytocin in units/mL. So, 0.72 units/hour ÷ 0.01 units/mL = 72 mL/hour. Therefore, the nurse should set the infusion pump to 72 mL/hour.
Correct Answer is C
Explanation
Choice A rationale
Variance in blood pressure across extremities is not typically associated with ventricular septal defects (VSDs). VSDs are characterized by a hole in the heart that allows oxygen-rich blood to move back into the lungs instead of being pumped to the rest of the body.
Choice B rationale
Hypotension is not a common symptom of VSDs. Instead, these defects can cause increased blood pressure in the lungs due to the abnormal flow of blood.
Choice C rationale
Tachycardia, or a rapid heart rate, is a common symptom of VSDs, especially in cases where the defect is medium or large. This is because the heart needs to work harder to pump blood, leading to an increased heart rate.
Choice D rationale
While pulse oximetry readings within defined limits could be seen in small VSDs, in larger defects or those causing heart failure, oxygen saturation levels might be lower due to the abnormal circulation of blood.
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