The baby's head is delivered at 0900. The shoulders are not delivered and you notice a turtle sign. Interventions to relieve a dystocia include (Select all that apply):
Enter maneuvers (wood screw or rubin) by physician
Put mother on all fours (gaskin)
Suprapubic pressure by the nurse
McRoberts by the nurse
Delivery of the anterior arm by the physician
Fundal pressure by the nurse
Correct Answer : A,B,C,D,E
Choice A: Enter maneuvers (wood screw or rubin) by physician are interventions to relieve a dystocia, as they involve rotating the fetal shoulders to align them with the maternal pelvis and facilitate the delivery. The physician can perform these maneuvers by applying pressure on the fetal clavicles or scapulas through the vaginA.
Choice B: Put mother on all fours (gaskin) is an intervention to relieve a dystocia, as it involves changing the maternal position to widen the pelvic outlet and reduce the pressure on the fetal shoulders. The mother can assume this position by kneeling on the bed and resting on her elbows or hands.
Choice C: Suprapubic pressure by the nurse is an intervention to relieve a dystocia, as it involves applying firm and downward pressure on the mother's lower abdomen to dislodge the anterior fetal shoulder from behind the pubic symphysis and assist the delivery. The nurse can perform this intervention by using the heel of the hand or a fist.
Choice D: McRoberts by the nurse is an intervention to relieve a dystocia, as it involves flexing and abducting the mother's legs to her chest to increase the pelvic diameter and relax the pelvic floor muscles. The nurse can perform this intervention by holding the mother's legs or using stirrups.
Choice E: Delivery of the anterior arm by the physician is an intervention to relieve a dystocia, as it involves reaching into the vagina and sweeping the fetal arm across the chest and out of the birth canal to reduce the shoulder-to-shoulder diameter and assist the delivery. The physician can perform this intervention by using a finger or a forceps.
Choice F: Fundal pressure by the nurse is not an intervention to relieve a dystocia, as it involves pushing on the upper part of the uterus to expel the fetus. This intervention is contraindicated in shoulder dystocia, as it can worsen the impaction of the fetal shoulders and cause fetal injury or maternal traumA.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Maternal pelvis is gynecoid is not a contributing factor of difficult, prolonged labor. On the contrary, a gynecoid pelvis is the most favorable shape for vaginal delivery, as it has a round inlet and a wide outlet that can accommodate the fetal heaD.
Choice B: Fetal position is persistent occiput posterior is a contributing factor of difficult, prolonged labor. In this position, the back of the fetal head is against the mother's sacrum, which can cause a poor fit in the pelvis and increase the resistance and the pressure on the maternal tissues. This can result in a longer and more painful labor, often associated with a severe backachE.
Choice C: Fetal attitude is in general flexion is not a contributing factor of difficult, prolonged labor. On the contrary, a general flexion attitude is the most optimal for vaginal delivery, as it allows the smallest diameter of the fetal head to pass through the birth canal.
Choice D: Fetal lie is longitudinal is not a contributing factor of difficult, prolonged labor. On the contrary, a longitudinal lie is the most common and favorable for vaginal delivery, as it means that the long axis of the fetus is parallel to the long axis of the mother.
Correct Answer is A
Explanation
B. Report the client's temperature elevation. This is not a priority action because the client's temperature is only slightly elevated and could be due to dehydration or normal postpartum changes. The nurse should monitor the temperature and report it if it persists or increases.
C. Increase IV fluids. This is not an appropriate action because the client's vital signs are stable and there is no evidence of excessive blood loss or shock. Increasing IV fluids could cause fluid overload or interfere with breastfeedinG.
D. Encourage the client to nurse more frequently so her milk will come in. This is not a relevant action because the client's breasts are soft, indicating that the milk has not come in yet. Nursing more frequently will not hasten the onset of lactation and could cause nipple soreness or engorgement. The nurse should support the client's breastfeeding efforts and provide education on proper latch and positioninG.
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