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 C
Explanation
Choice A rationale
While using gestures with 1 to 2 word sentences is a developmental milestone, it is typically seen in younger children, around the age of 212.
Choice B rationale
Using 1 word sentences is a developmental milestone usually achieved by children around the age of 112. By the age of 3, children are typically able to speak in simple sentences with four or more words.
Choice C rationale
Speaking in simple sentences with four or more words is a typical developmental milestone for a 3-year-old child. They are able to express their thoughts more clearly and engage in conversations.
Choice D rationale
Recognizing most letters and numbers is a skill that is typically developed around the age of 4 or 512. Therefore, expecting a 3-year-old child to recognize most letters and numbers might be too advanced for their developmental stage.
Correct Answer is A
Explanation
Choice A rationale
Disseminated intravascular coagulation (DIC) is a serious complication that can occur after severe postpartum hemorrhage. It involves an abnormal activation of the clotting cascade, leading to the formation of small blood clots in the vessels and can result in organ damage.
Choice B rationale
Postpartum psychosis is a rare psychiatric emergency that typically presents with delirium and mood disturbances, and it is not directly related to postpartum hemorrhage.
Choice C rationale
While hard, painful uterine afterpains can occur after childbirth, they are not the highest priority for assessment in a client who experienced a severe postpartum hemorrhage.
Choice D rationale
Placenta accreta is a condition where the placenta attaches too deeply into the uterine wall. However, it is typically identified during pregnancy or at the time of delivery, not after a postpartum hemorrhage.
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