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

Answer and Explanation

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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Correct Answer is A

Explanation

The correct answer is A. "It sounds like you are feeling sad that things didn't go as planned."

A. This response reflects empathy and acknowledges the client's feelings without judgment. It validates the client's emotions and provides an opportunity for her to express her feelings further.

B. "Maybe next time you can have a vaginal delivery" is not an appropriate response as it assumes that the client will or should have another pregnancy and may have a vaginal delivery. It is more important to address the current emotions and experience.

C. "At least you know you have a healthy baby" dismisses the client's feelings of disappointment. While the health of the baby is important, it's essential to acknowledge and validate the client's emotional experience.

D. "You can resume sexual relations sooner than if you had delivered vaginally" is not relevant to the client's expressed disappointment about the mode of delivery. It may not be an appropriate or comforting statement given the context.

A. "You can share your room with your baby for the next few weeks." B. "Cover your baby with a light blanket while sleeping" C. "Check the temperature of your baby's bath water with your hand." D. "Your baby can nap in the car seat during the daytime."

Correct Answer is C

Explanation

The correct instruction is C. "Check the temperature of your baby's bath water with your hand."

Explanation:

A. "You can share your room with your baby for the next few weeks": This is a recommended practice. The American Academy of Pediatrics (AAP) recommends room-sharing without bed-sharing for at least the first six months and ideally for the first year of a baby's life. It promotes safe sleep and reduces the risk of Sudden Infant Death Syndrome (SIDS).

B. "Cover your baby with a light blanket while sleeping": This instruction is not recommended. The AAP advises against using loose bedding, including blankets, in the sleep environment to reduce the risk of SIDS. It is safer to use sleep sacks or wearable blankets if additional warmth is needed.

C. "Check the temperature of your baby's bath water with your hand": This is the correct instruction. It is essential to ensure that the bathwater is not too hot to prevent burns. Checking with the hand is a practical way to assess the water temperature before placing the baby in the bath.

D. "Your baby can nap in the car seat during the daytime": While napping in a car seat during travel is acceptable, it is not recommended for routine or prolonged sleep. The upright position in a car seat may compromise the baby's airway, increasing the risk of breathing difficulties. It's advised to transfer the baby to a flat, firm sleep surface for regular naps.

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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?

Nursing Test Bank

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