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
Seizure activity typically presents with symptoms such as convulsions, loss of consciousness, or abnormal behavior, which are not described in the scenario.
Choice B rationale
Arrhythmia, or an abnormal heart rhythm, could potentially cause a sudden drop in oxygen saturation and cyanosis. It could also lead to a rapid response team being called.
Choice C rationale
Increased oxygen demand could potentially lead to low oxygen saturation. However, it would not typically cause cyanosis or require the rapid response team to be called unless it was associated with another condition such as heart or lung disease.
Choice D rationale
Acidosis, or a high level of acid in the body, could potentially cause low oxygen saturation. However, it would not typically cause cyanosis or require the rapid response team to be called unless it was severe or associated with another condition.
Correct Answer is ["A","B"]
Explanation
The correct answer is choiceA. Manual resuscitation bagandB. An advanced airway kit.
Choice A rationale:
A manual resuscitation bag is essential in pediatric emergencies to provide immediate ventilation support if the child experiences respiratory failure. Given the child’s symptoms of fast and noisy breathing, there is a risk of respiratory distress, making this equipment crucial.
Choice B rationale:
An advanced airway kit is necessary to secure the airway in case of severe respiratory distress or failure. This kit includes tools for intubation, which may be required if the child’s condition deteriorates and manual ventilation is insufficient.
Choice C rationale:
A dose of subcutaneous epinephrine is typically used for anaphylactic reactions. While it is a critical medication in emergencies involving severe allergic reactions, it is not directly related to managing respiratory distress caused by infections or other non-allergic conditions.
Choice D rationale:
The child’s favorite toy can provide comfort and reduce anxiety during medical procedures. However, it is not a critical item for the immediate management of respiratory distress or for the placement of an intravenous line.
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