Question

A nurse is caring for a client who is in the second stage of labor. The nurse observes the fetal head retract against the client's perineum immediately following emergence. Which of the following actions should the nurse take?

Answer 1

Correct Answers:

Apply pressure to the client's suprapubic area.

Rationale :

🔷 Retraction of the fetal head back against the perineum after it emerges is the “turtle sign,” which is a classic sign of shoulder dystocia.

🔷 Shoulder dystocia occurs when the anterior fetal shoulder becomes impacted behind the maternal pubic symphysis, preventing delivery of the shoulders.

🔷 This is an obstetric emergency because prolonged compression can reduce fetal oxygenation and increase risk for fetal injury.

🔷 The nurse should apply suprapubic pressure (with assistance as appropriate) to help dislodge the impacted anterior shoulder and facilitate delivery.

🔷 This maneuver reduces shoulder impaction by pushing the shoulder into a more favorable angle for birth.

❌ Assess fetal position using Leopold maneuvers is inappropriate during an active shoulder dystocia emergency. This delays urgent intervention and Leopold maneuvers are not used to resolve the impaction.

❌ Empty the client’s bladder using the Credé maneuver is incorrect. The Credé maneuver involves manual pressure over the bladder and is not a treatment for shoulder dystocia. It does not relieve impacted shoulders.

❌ Reposition the client in a left lateral position is not the priority intervention for shoulder dystocia. Specific maneuvers such as suprapubic pressure are indicated.

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Answer 2

Correct Answers:

9

Rationale :

Step 1: Convert units to milliunits

10 units × 1000 = 10,000 milliunits

Step 2: Determine concentration

10,000 milliunits ÷ 1000 mL = 10 milliunits/mL

Step 3: Calculate mL per minute

1.5 milliunits/min ÷ 10 milliunits/mL = 0.15 mL/min

Step 4: Convert to mL/hr

0.15 × 60 = 9 mL/hr

✅ IV pump setting = 9 mL/hr

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Answer 3

Correct Answers:

Assess abdominal rigidity.

Rationale :

🔷 Abruptio placentae involves premature separation of the placenta and can cause concealed or visible hemorrhage, uterine tenderness, and a firm, board-like abdomen.

🔷 Assessing abdominal rigidity is important because increased uterine tone or a rigid abdomen may indicate worsening placental separation and fetal compromise.

🔷 The nurse should monitor for pain, uterine tenderness, fetal distress, and signs of maternal shock.

🔷 This is a priority assessment action in a client with suspected or confirmed abruption.

🔷 At 35 weeks, prompt recognition of worsening status is critical for maternal-fetal safety.

❌ Perform a fundal massage is incorrect. Fundal massage is used for postpartum uterine atony, not placental abruption, and may worsen the situation.

❌ Administer betamethasone is generally used to promote fetal lung maturity in threatened preterm birth, often before 34 weeks. At 35 weeks with abruptio placentae, the priority is maternal-fetal stabilization, not this intervention.

❌ Conduct a sterile vaginal exam is inappropriate because vaginal exams can worsen bleeding risks and are not the priority in abruptio placentae.

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Answer 4

Correct Answers:

A uterine resting tone of 45 mm Hg during the infusion

Rationale :

💎 Amnioinfusion can help relieve recurrent variable decelerations, but a major complication is uterine overdistention, which may increase uterine resting tone.

💎 A resting tone of 45 mm Hg is elevated and suggests possible uterine hypertonicity/overdistention, which is a concerning complication.

💎 This can impair uteroplacental perfusion and threaten fetal oxygenation.

💎 The nurse should recognize this as abnormal and respond promptly.

💎 Elevated resting tone is the complication finding among the options.

❌ Volume of fluid returned is equal to the amount infused is expected and suggests fluid is not accumulating excessively.

❌ A fetal heart rate of 150/min is within normal baseline range (110–160/min).

❌ Moderate variability is a reassuring fetal status finding, not a complication.

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Answer 5

Correct Answers:

Station of the presenting part
Cervical dilation
Cervical effacement

Rationale :

Station of the presenting part

🔷 Station is part of the Bishop score because it shows how far the presenting fetal part has descended into the pelvis.

🔷 A lower presenting part indicates better fetal engagement and a more favorable cervix for induction.

🔷 Station is measured in relation to the maternal ischial spines, from negative numbers to positive numbers.

🔷 This finding helps predict whether induction is more likely to result in vaginal birth.

Cervical dilation

💎 Cervical dilation is included because it measures how open the cervix is in centimeters.

💎 Greater dilation means the cervix is more favorable and closer to active labor readiness.

💎 A cervix that is already dilated usually responds better to induction methods.

💎 This is one of the key cervical readiness indicators in the Bishop score.

Cervical effacement

✅ Cervical effacement is included because it measures how thin the cervix has become.

✅ Effacement is expressed as a percentage from 0% to 100%.

✅ A more effaced cervix is softer, thinner, and more prepared for labor.

✅ This improves the likelihood that induction will be successful.

❌ Contraction intensity is not part of the Bishop score. It helps evaluate labor progress, but not cervical readiness before induction.

❌ Contraction frequency is not part of the Bishop score. It is monitored during labor, but it is not used to calculate the Bishop score.

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Answer 6

Correct Answers:

Insert the diaphragm up to 6 hr before intercourse.

Rationale :

🔷 The diaphragm can be inserted up to 6 hours before intercourse, which allows flexibility while still providing contraception.

🔷 It should be used with spermicide, not regular vaginal lubricant, because spermicide helps immobilize or kill sperm.

🔷 The diaphragm must remain in place for at least 6 hours after intercourse to prevent pregnancy.

🔷 It should not remain in place longer than 24 hours because prolonged use increases infection risk.

🔷 The client should wash it with mild soap and water, not harsh detergent soap, because detergent can damage the diaphragm material.

❌ Wash diaphragm with detergent soap between uses is incorrect because harsh detergents can weaken or damage the diaphragm.

❌ Apply a vaginal lubricant to the diaphragm prior to insertion is incorrect because the diaphragm should be used with spermicide.

❌ Remove the diaphragm 2 to 4 hr after intercourse is incorrect because it must stay in place for at least 6 hours after intercourse.

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Answer 7

Correct Answers:

"This medication might cause an increase in your blood glucose level."

Rationale :

💎 Betamethasone is a corticosteroid given during preterm pregnancy to accelerate fetal lung maturity.

💎 It helps stimulate production of surfactant, which lowers the newborn’s risk of respiratory distress syndrome if preterm birth occurs.

💎 Because it is a corticosteroid, it can cause maternal hyperglycemia, which is especially important for a client with gestational diabetes mellitus.

💎 The nurse should teach the client that blood glucose may need closer monitoring after receiving the medication.

💎 Insulin or medication adjustments may be needed depending on provider orders and glucose trends.

❌ “This medication might cause ringing in your ears.” is not a typical expected effect of betamethasone.

❌ “This medication will prevent the onset of pre-term contractions.” is incorrect because betamethasone supports fetal lung maturity; it is not a tocolytic medication.

❌ “This medication will be given in a series of three doses.” is incorrect because betamethasone is commonly given as two IM doses 24 hours apart.

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Answer 8

Correct Answers:

"l will call if the temperature under my baby's arm is less than 36.3 C (97.70 F)."

Rationale :

🔷 A newborn with an axillary temperature below 36.3°C (97.7°F) may have hypothermia, which requires prompt follow-up.

🔷 Newborns lose heat easily because they have limited fat stores, immature temperature regulation, and a large body surface area.

🔷 Low temperature can increase the risk for hypoglycemia, respiratory distress, and poor feeding.

🔷 The parent should notify the pediatrician if the newborn is too cold, too warm, feeding poorly, difficult to wake, or showing signs of illness.

❌ More than 6 wet diapers/day is expected after milk intake is established.

❌ Three stools/day can be normal for a newborn.

❌ Waking every 2 hours is expected because newborns feed frequently.

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Answer 9

Correct Answers:

Fentanyl

Rationale :

💎 Fentanyl is an opioid analgesic commonly used during active labor to manage moderate to severe contraction pain when the client requests pharmacologic pain relief.

💎 It acts on the central nervous system to reduce pain perception while allowing the laboring client to remain conscious and participate in the birthing process.

💎 Fentanyl has a rapid onset and short duration, which makes it appropriate for labor because it provides pain relief without prolonged effects on the mother or newborn when properly timed.

💎 The nurse should monitor maternal respiratory status, fetal heart rate, and neonatal respiratory depression, because opioids can cross the placenta.

💎 Administering Fentanyl addresses the client’s immediate need for analgesia and is the most appropriate medication for intense pain during active labor.

Incorrect Options:

🔹 Terbutaline is a tocolytic used to suppress uterine contractions, often for preterm labor or uterine tachysystole. It does not provide pain relief and would not be used simply because a laboring client requests analgesia.

🔹 Naloxone is an opioid antagonist used to reverse opioid-induced respiratory depression. It is not a pain medication and would be used only if opioid overdose or neonatal respiratory depression occurred.

🔹 Acetaminophen may relieve mild discomfort or fever, but it is inadequate for intense active labor pain. It does not provide the level of analgesia needed during strong contractions.

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Answer 10

Correct Answers:

"Plan to spend individual time with your preschooler."

Rationale :

🌟 Preschool-aged children commonly experience jealousy, regression, and rivalry when a new sibling arrives because they may perceive the newborn as competition for parental attention.

🌟 Planning individual one-on-one time helps reassure the child they remain loved, valued, and secure, which promotes emotional adjustment to the new family role.

🌟 Maintaining routines and giving the preschooler opportunities to participate in simple baby-related tasks can also reduce anxiety and foster inclusion.

🌟 This intervention supports positive sibling bonding and decreases the likelihood of attention-seeking or regressive behaviors, such as toileting accidents or tantrums.

🌟 Preserving the preschooler’s emotional connection with the parent is a priority in preparing them for a new sibling.

Incorrect Options:

🔹 “Ensure that your preschooler sees you holding the baby during the initial encounter” is not recommended. The first meeting is usually more therapeutic if the parent greets the preschooler first without holding the newborn, helping the child feel prioritized.

🔹 “Avoid bringing your preschooler to prenatal visits” is incorrect. Age-appropriate inclusion in pregnancy preparation can help the child feel involved and reduce fear of the unknown.

🔹 “Move your preschooler from their crib to a bed the day before the baby comes home” is incorrect. Major transitions should occur weeks before the newborn arrives so the child does not associate losing the crib with the baby.

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QLexNursing

1 :
A nurse is caring for a client who is in the second stage of labor. The nurse observes the fetal head retract against the client's perineum immediately following emergence. Which of the following actions should the nurse take?

3 :
A nurse is caring for a client who is at 35 weeks of gestation and has abruptio placenta. Which of the following actions should the nurse take?

4 :
A nurse is caring for a client who is receiving an amnioinfusion. Which of the following manifestations is an indication of a potential complication of this procedure?

5 :
A nurse is determining a Bishop score for a client who is scheduled for labor induction. Which of the following findings should the nurse assess? (Select all that apply.)

6 :
A nurse is providing instructions to a client who has chosen a diaphragm for birth control. Which of the following instructions should the nurse include?

7 :
A nurse is preparing to administer betamethasone to a client who is at 30 weeks of gestation and has gestational diabetes mellitus. Which of the following statements should the nurse make to the client?

8 :
. A nurse is teaching a parent of a newborn about reasons to call a pediatrician. Which of the following statements by the parent indicates an understanding of the teaching?

9 :
A nurse is caring for a client who is in active labor. The client reports intense pain with contractions and requests pain medication. Which of the following medications should the nurse plan to administer?

10 :
A nurse in a clinic is caring for a client who is antepartum. The client expresses concern about preparing their preschooler for a new sibling. Which of the following responses should the nurse make?

QLexNursing

1 : A nurse is caring for a client who is in the second stage of labor. The nurse observes the fetal head retract against the client's perineum immediately following emergence. Which of the following actions should the nurse take?

3 : A nurse is caring for a client who is at 35 weeks of gestation and has abruptio placenta. Which of the following actions should the nurse take?

4 : A nurse is caring for a client who is receiving an amnioinfusion. Which of the following manifestations is an indication of a potential complication of this procedure?

5 : A nurse is determining a Bishop score for a client who is scheduled for labor induction. Which of the following findings should the nurse assess? (Select all that apply.)

6 : A nurse is providing instructions to a client who has chosen a diaphragm for birth control. Which of the following instructions should the nurse include?

7 : A nurse is preparing to administer betamethasone to a client who is at 30 weeks of gestation and has gestational diabetes mellitus. Which of the following statements should the nurse make to the client?

8 : . A nurse is teaching a parent of a newborn about reasons to call a pediatrician. Which of the following statements by the parent indicates an understanding of the teaching?

9 : A nurse is caring for a client who is in active labor. The client reports intense pain with contractions and requests pain medication. Which of the following medications should the nurse plan to administer?

10 : A nurse in a clinic is caring for a client who is antepartum. The client expresses concern about preparing their preschooler for a new sibling. Which of the following responses should the nurse make?

1 :
A nurse is caring for a client who is in the second stage of labor. The nurse observes the fetal head retract against the client's perineum immediately following emergence. Which of the following actions should the nurse take?

3 :
A nurse is caring for a client who is at 35 weeks of gestation and has abruptio placenta. Which of the following actions should the nurse take?

4 :
A nurse is caring for a client who is receiving an amnioinfusion. Which of the following manifestations is an indication of a potential complication of this procedure?

5 :
A nurse is determining a Bishop score for a client who is scheduled for labor induction. Which of the following findings should the nurse assess? (Select all that apply.)

6 :
A nurse is providing instructions to a client who has chosen a diaphragm for birth control. Which of the following instructions should the nurse include?

7 :
A nurse is preparing to administer betamethasone to a client who is at 30 weeks of gestation and has gestational diabetes mellitus. Which of the following statements should the nurse make to the client?

8 :
. A nurse is teaching a parent of a newborn about reasons to call a pediatrician. Which of the following statements by the parent indicates an understanding of the teaching?

9 :
A nurse is caring for a client who is in active labor. The client reports intense pain with contractions and requests pain medication. Which of the following medications should the nurse plan to administer?

10 :
A nurse in a clinic is caring for a client who is antepartum. The client expresses concern about preparing their preschooler for a new sibling. Which of the following responses should the nurse make?