Question

A woman with uncontrolled gestational diabetes who has received an epidural for pain relief is giving birth. The nurse observes that the fetal head emerges and then retracts against the perineum with several contractions. Which initial interventions does the nurse anticipate? Select all that apply.

Answer 1

Correct Answers:

Suprapubic pressure
McRoberts knees-to-chest maneuver

Rationale :

Suprapubic pressure

🔷 Suprapubic pressure is an initial intervention for shoulder dystocia, especially when the fetal head emerges and then retracts against the perineum, known as the turtle sign.

🔷 This maneuver helps dislodge the fetal anterior shoulder from behind the maternal symphysis pubis.

🔷 Pressure is applied above the pubic bone in a downward and lateral direction to reduce the shoulder diameter.

🔷 This action improves the chance of vaginal delivery without pulling forcefully on the fetal head.

🔷 It is especially anticipated in this client because uncontrolled gestational diabetes increases the risk for fetal macrosomia and shoulder dystocia.

McRoberts knees-to-chest maneuver

🔷 McRoberts knees-to-chest maneuver is a first-line intervention for shoulder dystocia.

🔷 The nurse flexes the client’s thighs sharply toward the abdomen to widen the pelvic outlet.

🔷 This position straightens the sacrum and rotates the pelvis to help release the impacted shoulder.

🔷 It is noninvasive, quick, and commonly performed together with suprapubic pressure.

🔷 Because the client has an epidural, staff assistance is needed to safely move her legs into position.

Gaskin maneuver

🔷Gaskin maneuver involves placing the client on hands and knees to relieve shoulder dystocia.

🔷This may be used if initial maneuvers fail, but it is not usually the first anticipated intervention, especially with an epidural.

Amniocentesis

🔷Amniocentesis is not an intervention for shoulder dystocia.

🔷It is a prenatal diagnostic procedure and has no role during an emergency birth complication.

Uterine fundal pressure

🔷Uterine fundal pressure is contraindicated because it can worsen shoulder impaction.

🔷It increases the risk of fetal injury, brachial plexus trauma, and uterine rupture.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Apply manual manipulation to the presenting part and change the maternal position

Rationale :

🟣 A palpable loop of cord beside the fetal head with fetal bradycardia indicates umbilical cord prolapse.

🟣 The priority is to immediately relieve pressure from the cord because compression blocks oxygenated blood flow to the fetus.

🟣 The nurse should insert a sterile gloved hand into the vagina and lift the presenting fetal part off the cord.

🟣 The client should also be placed in knee-chest, Trendelenburg, or side-lying with hips elevated to decrease cord compression.

🟣 This emergency intervention helps maintain fetal oxygenation while preparation is made for urgent birth, often by cesarean delivery.

Insert a fetal scalp electrode and closely monitor the fetal heart rate

🟣Insert a fetal scalp electrode and closely monitor the fetal heart rate delays the life-saving intervention.

🟣Monitoring confirms fetal distress but does not relieve the cord compression.

Press on the uterine fundus and ask the woman to push with the next contraction

🟣Press on the uterine fundus and ask the woman to push with the next contraction can worsen compression of the prolapsed cord.

🟣Pushing increases pressure on the cord and can further reduce fetal oxygenation.

Apply manual pressure to the loop of cord and insert an intrauterine pressure catheter

🟣 Apply manual pressure to the loop of cord and insert an intrauterine pressure catheter is unsafe because the cord should not be pressed or manipulated directly.

🟣The nurse should relieve pressure from the presenting part, not place pressure on the cord.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

Each contraction and bearing down effort

Rationale :

🟢 The second stage of labor begins with complete cervical dilation and ends with birth of the newborn.

🟢 During this stage, the nurse assesses each contraction because contractions drive fetal descent.

🟢 Bearing down efforts must be evaluated to determine whether pushing is effective and coordinated.

🟢 The nurse also observes fetal descent, maternal fatigue, fetal heart rate response, and signs of crowning.

🟢 Frequent assessment is important because prolonged or ineffective pushing can increase maternal exhaustion and fetal stress.

Fetal heart rate every 2 hours

🟢Fetal heart rate every 2 hours is far too infrequent during the second stage of labor.

🟢Fetal heart rate should be assessed frequently because pushing and contractions can reduce fetal oxygenation.

Maternal temperature every 15 minutes

🟢Maternal temperature every 15 minutes is not the main assessment during the second stage.

🟢Temperature is monitored as needed, but contraction pattern, fetal response, and pushing effectiveness are more urgent.

Vaginal exams for cervical change

🟢Vaginal exams for cervical change are more relevant during the first stage of labor.

🟢In the second stage, the cervix is already fully dilated, so the focus shifts to descent and birth.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

The patient has dry mucous membranes

Rationale :

💎 Dry mucous membranes indicate possible dehydration, which is concerning in persistent nausea and vomiting during pregnancy.

💎 Continued vomiting at 20 weeks may suggest hyperemesis gravidarum rather than normal early pregnancy nausea.

💎 Dehydration can lead to electrolyte imbalance, weight loss, ketonuria, and maternal-fetal compromise.

💎 The nurse should be concerned because fluid volume deficit can progress quickly if vomiting continues.

💎 This finding requires further assessment of intake, output, weight, urine ketones, and electrolytes.

The patient dislikes the taste of ginger

💎Disliking ginger is not a danger sign.

💎It only affects whether ginger can be used as a comfort measure.

The patient works 40 hours per week in an office

💎Working full time is not automatically abnormal.

💎It becomes concerning only if symptoms impair hydration, nutrition, or safety.

The patient avoids eating spicy foods

💎Avoiding spicy foods is a common strategy to reduce nausea.

💎It does not indicate a complication.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

Support the patient as she grieves the likely removal of her uterus

Rationale :

♦️ Placenta percreta is the most severe form of placenta accreta spectrum, where placental tissue grows through the uterine wall.

♦️ This condition creates a very high risk for massive hemorrhage during delivery.

♦️ Management commonly involves planned cesarean birth with hysterectomy to control bleeding.

♦️ The nurse should provide emotional support because loss of the uterus affects fertility, body image, and grief response.

♦️ Supportive care includes therapeutic communication, preparation for surgery, and coordination with a multidisciplinary team.

Educate the patient on the effects of a low-lying placenta

♦️A low-lying placenta describes placenta previa, not placenta percreta.

♦️Placenta percreta involves abnormal invasion into or through the uterus.

Prepare the patient for the inevitable loss of this baby

♦️Placenta percreta does not mean fetal loss is inevitable.

♦️The major maternal risk is severe hemorrhage and possible hysterectomy.

Ask if the patient has recently been in a motor vehicle accident

♦️Trauma is more associated with placental abruption.

♦️Placenta percreta is related to abnormal placental attachment and invasion.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

Blood pressure and lochia

Rationale :

🔹 The first 2 hours after birth are the highest-risk period for postpartum hemorrhage.

🔹 Assessing blood pressure helps identify hypovolemia or shock from excessive blood loss.

🔹 Assessing lochia helps determine the amount and character of postpartum bleeding.

🔹 The nurse should also assess uterine tone because a boggy uterus can cause heavy bleeding.

🔹 Early recognition of abnormal bleeding prevents severe maternal complications.

Nausea and vomiting

🔹These can occur after birth but are not the priority assessment.

🔹Hemorrhage surveillance is more urgent.

Bladder sensation and urinary retention

🔹Bladder assessment is important because retention can interfere with uterine contraction.

🔹It is not more important than blood pressure and bleeding assessment.

Temperature and thirst

🔹Temperature is usually monitored postpartum, but infection is not the most immediate concern in the first 2 hours.

🔹Thirst alone does not provide enough information about hemorrhage risk.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

Decreased level of consciousness.

Rationale :

🟣 Decreased level of consciousness is concerning because it can indicate magnesium sulfate toxicity.

🟣 Magnesium toxicity depresses the central nervous system and may progress to respiratory depression.

🟣 The nurse should assess respiratory rate, deep tendon reflexes, urine output, and serum magnesium level.

🟣 Magnesium is excreted by the kidneys, so reduced clearance increases toxicity risk.

🟣 The provider should be notified, magnesium may need to be stopped, and calcium gluconate should be available as the antidote.

Blood pressure 150/76

🟣This is elevated but expected in a client being treated for preeclampsia.

🟣It is not the clearest sign of magnesium toxicity.

16 breaths per minute

🟣This respiratory rate is within an acceptable range.

🟣Respiratory depression is more concerning when respirations fall significantly.

Deep tendon reflexes of 2+

🟣A 2+ reflex is normal.

🟣Loss or marked decrease of reflexes is more concerning for magnesium toxicity.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Stop the administration of oxytocin

Rationale :

✅ Seven contractions in 10 minutes indicates uterine tachysystole.

✅ Oxytocin can overstimulate the uterus, reducing uteroplacental blood flow.

✅ The fetal heart rate rising to 180 for 10 minutes indicates fetal tachycardia, a concerning fetal response.

✅ The priority is to stop oxytocin to reduce contraction frequency and improve fetal oxygenation.

✅ After stopping oxytocin, the nurse should reposition the client, increase IV fluids as ordered, and notify the provider.

Medicate the client for pain

✅Pain medication does not correct uterine tachysystole.

✅The immediate problem is excessive contractions with fetal heart rate changes.

Place the client in Trendelenburg position

✅Trendelenburg is not the priority for oxytocin-induced tachysystole.

✅Lateral positioning is generally preferred to improve uteroplacental perfusion.

Administer oxygen by non-rebreather mask

✅Oxygen may be used depending on facility protocol and fetal status.

✅However, the first priority is removing the cause by stopping oxytocin.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

Dysfunctional labor

Rationale :

🟢 A fetus in left occiput posterior position may not fit through the pelvis as efficiently as an anterior position.

🟢 This position is associated with prolonged labor, intense back pain, and slower fetal descent.

🟢 Ineffective rotation can cause poor progress despite contractions.

🟢 The nurse should monitor labor pattern, fetal descent, maternal fatigue, and fetal heart rate.

🟢 Position changes, hands-and-knees positioning, and supportive measures may help fetal rotation.

Hypoglycemia

🟢Hypoglycemia is not a typical complication of fetal occiput posterior position.

🟢It is more related to neonatal glucose regulation or maternal diabetes.

Cord prolapse

🟢Cord prolapse is more associated with ruptured membranes and an unengaged presenting part.

🟢Occiput posterior position mainly affects labor progress.

Amniotic fluid embolism

🟢This is a rare emergency involving amniotic fluid entering maternal circulation.

🟢It is not specifically caused by LOP fetal position.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

Provide emotional support
Assess fetal heart tones
Obtain maternal vital signs
Notify the provider

Rationale :

🌺 Severe painless vaginal bleeding in pregnancy is highly suggestive of placenta previa, where the placenta partially or completely covers the cervical opening.

🌺 Assessing fetal heart tones is essential because heavy maternal bleeding can reduce placental oxygen delivery and place the fetus at risk for hypoxia.

🌺 Obtaining maternal vital signs helps identify early signs of hypovolemia, such as tachycardia, hypotension, dizziness, or shock.

🌺 Notifying the provider is a priority because placenta previa can require urgent interventions, including continuous monitoring, blood replacement, or cesarean birth.

🌺 Providing emotional support helps reduce fear and anxiety while the nurse performs urgent maternal and fetal assessments.

Massage the uterine fundus

🌺 Fundal massage is appropriate after birth when the uterus is boggy from uterine atony.

🌺 In a pregnant client with suspected placenta previa, uterine manipulation can worsen bleeding and does not address the cause of hemorrhage.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

2 :
After a laboring woman's membranes rupture spontaneously, the fetal heart rate drops to 100 beats per minute. The nurse performs a sterile vaginal exam and palpates a loop of umbilical cord beside the fetal head. What is the priority action for the nurse?

3 :
The nurse is caring for a pregnant client in the second stage of labor. What does the nurse assess?

4 :
A G1P0 pregnant patient presents to the clinic at 20 weeks gestation with complaints of continued nausea and vomiting. What additional information causes the nurse to become concerned?

5 :
A pregnant patient at 34 weeks gestation and G2P1 has been diagnosed with placenta percreta. What action does the nurse take?

6 :
The patient in the labor and delivery unit has just given birth vaginally to a healthy newborn. What is the priority maternal assessment by the nurse in the first 2 hours following the birth?

7 :
A pregnant patient at 35 weeks gestation is receiving an IV infusion of magnesium sulfate for preeclampsia. What assessment finding concerns the nurse?

9 :
The nurse is caring for a G2P1 patient in labor at 39 weeks gestation with a fetus in left occiput posterior (LOP) position. What complication is the nurse alert for with this patient?

10 :
A pregnant client is admitted to the labor and delivery unit with severe vaginal bleeding. She denies any pain. Which actions does the nurse take? Select all that apply.

QLexNursing

2 : After a laboring woman's membranes rupture spontaneously, the fetal heart rate drops to 100 beats per minute. The nurse performs a sterile vaginal exam and palpates a loop of umbilical cord beside the fetal head. What is the priority action for the nurse?

3 : The nurse is caring for a pregnant client in the second stage of labor. What does the nurse assess?

4 : A G1P0 pregnant patient presents to the clinic at 20 weeks gestation with complaints of continued nausea and vomiting. What additional information causes the nurse to become concerned?

5 : A pregnant patient at 34 weeks gestation and G2P1 has been diagnosed with placenta percreta. What action does the nurse take?

6 : The patient in the labor and delivery unit has just given birth vaginally to a healthy newborn. What is the priority maternal assessment by the nurse in the first 2 hours following the birth?

7 : A pregnant patient at 35 weeks gestation is receiving an IV infusion of magnesium sulfate for preeclampsia. What assessment finding concerns the nurse?

9 : The nurse is caring for a G2P1 patient in labor at 39 weeks gestation with a fetus in left occiput posterior (LOP) position. What complication is the nurse alert for with this patient?

10 : A pregnant client is admitted to the labor and delivery unit with severe vaginal bleeding. She denies any pain. Which actions does the nurse take? Select all that apply.

2 :
After a laboring woman's membranes rupture spontaneously, the fetal heart rate drops to 100 beats per minute. The nurse performs a sterile vaginal exam and palpates a loop of umbilical cord beside the fetal head. What is the priority action for the nurse?

3 :
The nurse is caring for a pregnant client in the second stage of labor. What does the nurse assess?

4 :
A G1P0 pregnant patient presents to the clinic at 20 weeks gestation with complaints of continued nausea and vomiting. What additional information causes the nurse to become concerned?

5 :
A pregnant patient at 34 weeks gestation and G2P1 has been diagnosed with placenta percreta. What action does the nurse take?

6 :
The patient in the labor and delivery unit has just given birth vaginally to a healthy newborn. What is the priority maternal assessment by the nurse in the first 2 hours following the birth?

7 :
A pregnant patient at 35 weeks gestation is receiving an IV infusion of magnesium sulfate for preeclampsia. What assessment finding concerns the nurse?

9 :
The nurse is caring for a G2P1 patient in labor at 39 weeks gestation with a fetus in left occiput posterior (LOP) position. What complication is the nurse alert for with this patient?

10 :
A pregnant client is admitted to the labor and delivery unit with severe vaginal bleeding. She denies any pain. Which actions does the nurse take? Select all that apply.