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 B
Explanation
A. Administering oxygen at 10 L/min via a nonrebreather mask is an important intervention, but changing the client's position is the priority action when late decelerations are observed. Oxygen administration can follow, but optimizing uteroplacental perfusion through changing position is crucial.
B. Changing the client's position is the correct first action.
Repositioning the client, particularly from a supine to a side-lying position, can help alleviate compression on the vena cava and improve blood flow to the uterus, reducing the likelihood of late decelerations.
C. Applying a fetal scalp electrode is not the initial action when late decelerations are noted. Repositioning the client should be attempted first to address potential issues related to uteroplacental perfusion.
D. Increasing the rate of the intravenous (IV) infusion might not directly address the issue of late decelerations. It's important to focus on maternal positioning first to improve blood flow to the uterus.
Correct Answer is D
Explanation
The correct answer is D. Variable decelerations.
A. Accelerations in the fetal heart rate are generally considered reassuring. Accelerations are an indication of fetal well-being and are often seen in response to fetal movement.
B. Early decelerations are typically associated with head compression during contractions and are considered a normal response to the pressure on the fetal head.
C. Late decelerations are indicative of uteroplacental insufficiency.
Late decelerations occur after the peak of the contraction and are associated with inadequate oxygenation to the fetus. This pattern raises concerns about the baby's well-being.
D. Variable decelerations are associated with umbilical cord compression.
Variable decelerations are abrupt decreases in the fetal heart rate that vary in duration, depth, and timing. They often coincide with contractions and suggest compression or occlusion of the umbilical cord.
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