A nurse is performing Leopold maneuvers on a client who is in labor and determines the fetus is in an RSA position. Which of the following fetal presentations should the nurse document in the client's medical record?
Shoulder
Breech
Vertex
Mentum
The Correct Answer is B
A. Shoulder presentation is not typically described using the terms RSA. Shoulder presentation would be noted differently, and it is uncommon.
B. Breech presentation involves the presentation of the fetus with the buttocks or feet first. RSA indicates the specific position of the sacrum in relation to the mother's right side.
C. Vertex presentation refers to the head-first position, and it is not described using the terms RSA.
D. Mentum presentation is not a standard term used to describe fetal presentation. Mentum typically refers to the chin, and fetal presentations are commonly described in terms of the presenting part (e.g., vertex, breech).
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Related Questions
Correct Answer is D
Explanation
A. Decreased vaginal discharge is not typically associated with the onset of labor. In fact, an increase in vaginal discharge may be observed as the cervix begins to soften and efface.
B. Weight gain of 0.5 to 1.5 kg is not a specific sign that precedes labor. Weight gain during late pregnancy is more related to fluid retention, and it does not necessarily indicate imminent labor.
C. Urinary retention is not a common sign that precedes labor. However, increased pressure on the bladder from the descending fetus may lead to more frequent urination rather than retention.
D. A surge of energy is known as the "nesting instinct" and is a common sign that precedes labor. Some women experience a burst of energy and motivation to prepare for the upcoming birth.
Correct Answer is A
Explanation
A. Prepare equipment needed for newborn resuscitation.
A. Preparing equipment needed for newborn resuscitation is the correct action.
Meconium-stained amniotic fluid can increase the risk of meconium aspiration syndrome in the newborn. While the fetal heart rate is reassuring, being prepared for potential newborn resuscitation is prudent given the meconium staining.
B. Performing endotracheal suctioning as soon as the fetal head is delivered is not the current standard of care. The American Academy of Pediatrics (AAP) no longer recommends routine suctioning of meconium-stained infants unless they show signs of respiratory distress, poor muscle tone, or a depressed heart rate.
C. Preparing the client for an ultrasound examination is not the immediate priority. Meconium-stained amniotic fluid may be associated with fetal distress, but the focus should be on the current labor and delivery situation.
D. Preparing the client for an emergency cesarean birth is not the first action.
The presence of meconium staining alone does not necessarily indicate the need for an emergency cesarean birth, especially if the fetal heart rate is reassuring.
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