A nurse is assisting with the care of a client who is in the second stage of labor.
The nurse observes retraction of the fetal head against the maternal perineum as the head is birthed.
Which of the following actions should the nurse take?
Prepare for the delivery of the shoulders.
Encourage the mother to push during the next contraction.
Call for additional medical support.
Administer pain relief medication.
The Correct Answer is A
Choice A rationale:
Normal progression of labor: After the fetal head is delivered, the shoulders typically follow immediately. The nurse should be prepared to assist with the delivery of the shoulders to ensure a safe and smooth birth process.
Significance of retraction: Retraction of the fetal head against the maternal perineum, also known as the "turtle sign," is a classic indicator of shoulder dystocia. While this sign does not guarantee shoulder dystocia, it warrants immediate preparation for potential management.
Anticipating shoulder dystocia: By anticipating the possibility of shoulder dystocia, the nurse can take proactive measures to minimize risks and facilitate delivery. These measures may include:
Positioning the mother appropriately (e.g., McRoberts maneuver)
- Applying suprapubic pressure
- Performing internal maneuvers (e.g., Rubin's maneuver)
- Breaking the clavicle (in extreme cases)
Choice B rationale:
Ineffective in shoulder dystocia: Encouraging the mother to push during the next contraction is not an effective intervention
for shoulder dystocia. In fact, excessive pushing can worsen the impaction of the shoulders and potentially lead to
complications such as fetal hypoxia, brachial plexus injury, or maternal perineal trauma.
Choice C rationale:
Necessary in confirmed dystocia: Calling for additional medical support is crucial if shoulder dystocia is confirmed. However,
immediate preparation for shoulder delivery should commence without delay, as prompt action is essential to prevent adverse
outcomes.
Choice D rationale:
Secondary concern: While pain relief medication may be administered for maternal comfort, it is not a priority intervention in
this situation. The primary focus should be on managing the potential shoulder dystocia and ensuring the safe delivery of the
baby.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice c. The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm above the ischial spines.
Choice A rationale:
This choice incorrectly states that the cervix is effaced 3 cm and dilated 30%. Effacement is measured in percentages, not centimeters, and dilation is measured in centimeters, not percentages.
Choice B rationale:
This choice correctly states the cervix is dilated 3 cm and effaced 30%, but it incorrectly states that the presenting part is 1 cm below the ischial spines. A station of -1 means the presenting part is 1 cm above the ischial spines.
Choice C rationale:
This choice correctly states that the cervix is dilated 3 cm, effaced 30%, and the presenting part is 1 cm above the ischial spines. This matches the documentation provided.
Choice D rationale:
This choice incorrectly states that the cervix is effaced 3 cm and dilated 30%. Effacement is measured in percentages, not centimeters, and dilation is measured in centimeters, not percentages. Additionally, it incorrectly states that the presenting part is 1 cm below the ischial spines. A station of -1 means the presenting part is 1 cm above the ischial spines.
Correct Answer is C
Explanation
Choice A rationale:
Gestational hypertension is a condition characterized by elevated blood pressure during pregnancy. While it can increase the
risk of certain complications, it is not directly associated with an increased risk of postpartum hemorrhage. This is because
gestational hypertension primarily affects the vascular system, not the uterine muscle function, which is responsible for
controlling postpartum bleeding.
Choice B rationale:
A small for gestational age newborn (SGA) is a baby who is smaller than expected for their gestational age. While SGA can be
associated with some pregnancy complications, it is not a direct risk factor for postpartum hemorrhage. The size of the baby
does not have a significant impact on the ability of the uterus to contract and prevent excessive bleeding after delivery.
Choice C rationale:
Precipitous birth is defined as a labor that progresses very rapidly, with delivery occurring within three hours or less of the
onset of regular contractions. This rapid progression of labor can lead to postpartum hemorrhage for several reasons:
Uterine atony: The uterus may not have enough time to contract effectively after a rapid delivery, leading to increased
bleeding.
Lacerations and trauma: The rapid passage of the baby through the birth canal can increase the risk of tearing of the cervix,
vagina, or perineum, which can contribute to blood loss.
Retained placenta: The placenta may not separate from the uterine wall as easily after a precipitous birth, increasing the risk
of hemorrhage.
Choice D rationale:
A two-vessel umbilical cord is a variation in which the umbilical cord contains only two blood vessels (one vein and one
artery) instead of the usual three (one vein and two arteries). While this can be associated with certain fetal anomalies, it is not
a direct risk factor for postpartum hemorrhage. The number of blood vessels in the umbilical cord does not significantly
impact the ability of the uterus to contract and prevent bleeding after delivery.
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