During the second stage of labor, 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 anticipate performing to assist the healthcare provider?
Prepare 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 when the fetal head retracts against the perineum during the second stage of labor.
Choice B rationale
Applying suprapubic pressure can help guide the baby’s head out. This is a common practice during the second stage of labor when the baby’s head retracts against the perineum.
Choice C rationale
Applying fundal pressure is not typically done when the fetal head retracts against the perineum. Fundal pressure can be used to assist in the delivery of the baby, but it’s not the first action to take in this situation.
Choice D rationale
Preparing forceps is not the first action to take when the fetal head retracts against the perineum. Forceps are used to assist in the delivery of a baby, but only when necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While it’s important to evaluate the parent’s ability to care for the child, this does not directly address the parent’s fear of needles. The parent’s fear of needles is a specific issue that needs to be addressed in order to ensure the child receives the necessary insulin injections.
Choice B rationale
Determining if the child can administer the insulin is a potential solution to the parent’s fear of needles. Some children as young as 10 years old may be able to administer their own insulin injections with proper training and supervision. This would allow the child to manage their diabetes independently and alleviate the parent’s fear of needles.
Choice C rationale
Encouraging the parent to handle the needles may not be effective if the parent has a significant fear of needles. It’s important to respect the parent’s fear and find alternative solutions, such as having the child administer the insulin or finding another person who can assist with the injections.
Choice D rationale
Inquiring if there is another person who can assist with the injections is a potential solution to the parent’s fear of needles. If there is another person available who is comfortable administering the insulin injections, this could alleviate the parent’s fear and ensure the child receives the necessary care.
Correct Answer is ["25"]
Explanation
Answer and explanation
Step 1 is to convert the child’s weight from pounds to kilograms since the dosage is prescribed in mg/kg. We know that 1 kg is approximately 2.2 lbs. So, the child’s weight in kg is 55 lbs ÷ 2.2 = 25 kg (rounded to the nearest whole number for simplicity).
Step 2 is to calculate the total daily dosage. The prescription is for isoniazid 10 mg/kg/day. So, the total daily dosage in mg is 10 mg/kg/day × 25 kg = 250 mg/day.
Step 3 is to calculate the volume of the oral solution to administer. The bottle is labeled, “Isoniazid Oral Solution, USP 50 mg per 5 mL.”. So, the volume in mL to administer is (250 mg/day ÷ 50 mg) × 5 mL = 25 mL. Therefore, the nurse should administer 25 mL of the Isoniazid Oral Solution, USP 50 mg per 5 mL, once a day.
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