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 reason: This is not the most concerning vital sign because a heart rate of 99 is within the normal range for an adult. The nurse should monitor the patient's heart rate and rhythm, but it is not a sign of magnesium toxicity or adverse effects.
Choice B reason: This is the most concerning vital sign because a respiratory rate of 9 is below the normal range for an adult and indicates respiratory depression, which is a sign of magnesium toxicity. The nurse should stop the infusion, notify the provider, and prepare to administer calcium gluconate as an antidotE.
Choice C reason: This is not the most concerning vital sign because a BP of 99/69 is within the normal range for an adult. The nurse should monitor the patient's blood pressure and fluid status, but it is not a sign of magnesium toxicity or adverse effects.
Choice D reason: This is not the most concerning vital sign because a temperature of 99.9 is within the normal range for an adult. The nurse should monitor the patient's temperature and infection signs, but it is not a sign of magnesium toxicity or adverse effects.
Correct Answer is D
Explanation
Choice A: Placing a soft pillow under the client's buttocks is not an effective action, as it can increase the pressure and the swelling on the perineal area and worsen the pain. The nurse should avoid placing anything under the client's buttocks and encourage the client to lie on the side or sit on a firm surfacE.
Choice B: Preparing a warm sitz bath is not an appropriate action, as it can increase the blood flow and the inflammation on the perineal area and worsen the pain. The nurse should avoid using heat on the perineum for the first 24 hours after delivery and use cold therapy insteaD.
Choice C: Positioning a heating lamp toward the episiotomy is not an appropriate action, as it can cause burns and infections on the perineal area and worsen the pain. The nurse should avoid using heat on the perineum for the first 24 hours after delivery and use cold therapy insteaD.
Choice D: Applying an ice pack to the perineum is an effective action, as it can reduce the blood flow and the inflammation on the perineal area and relieve the pain. The nurse should apply an ice pack wrapped in a towel or a disposable cold pack to the perineum for 10 to 20 minutes every 2 to 4 hours for the first 24 hours after delivery.
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