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A nurse is caring for a client who is in the second stage of labor and is experiencing a shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver. Which of the following actions should the nurse take?
- A. Apply pressure to the client's fundus.
- B. Press firmly on the client’s suprapubic area.
- C. Move the client onto their hands and knees.
- D. Assist the client in pulling their knees toward their abdomen.
Correct Answer: D
Rationale: The correct answer is D: Assist the client in pulling their knees toward their abdomen. In shoulder dystocia, the McRoberts maneuver involves hyperflexing the mother's legs to rotate the pelvis, allowing the baby's shoulder to dislodge. This action enlarges the pelvic outlet, facilitating the delivery of the baby. Applying pressure to the fundus (A) or pressing on the suprapubic area (B) are not appropriate interventions for shoulder dystocia. Moving the client onto their hands and knees (C) may be helpful in some cases but is not the initial step for the McRoberts maneuver.
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A nurse is teaching about home safety with a client who is 2 days postpartum. Which of the following instructions should the nurse include in the teaching?
- A. Bathe your baby immediately after a feeding.
- B. Place a bumper pad in your baby’s crib.
- C. Put a soft mattress in your baby’s crib.
- D. Wash your baby’s face with plain water.
Correct Answer: D
Rationale: The correct answer is D: Wash your baby's face with plain water. This instruction is important because newborns have sensitive skin that can easily become irritated by soaps or cleansers. Using plain water is gentle and safe for the baby's delicate skin. Additionally, washing the baby's face helps to keep the area clean and prevent any buildup of milk or debris that can lead to skin irritation or infections.
Choice A is incorrect because bathing a baby immediately after a feeding can increase the risk of spitting up or discomfort due to handling on a full stomach. Choice B is incorrect as bumper pads pose a suffocation risk for infants. Choice C is incorrect because a soft mattress can increase the risk of Sudden Infant Death Syndrome (SIDS).
A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?
- A. Single palmar creases (p200Down Syndrome)
- B. Rust-stained urine
- C. Transient circumoral cyanosis
- D. Subconjunctival hemorrhage
Correct Answer: A
Rationale: The correct answer is A: Single palmar creases (p200Down Syndrome). This is an important finding as it can indicate the presence of Down Syndrome in the newborn. It is important to report this to the provider promptly for further evaluation and management. Single palmar creases are not typically seen in healthy newborns.
Rust-stained urine (choice B) is likely due to urate crystals, which can be a normal finding in newborns and usually resolves on its own. Transient circumoral cyanosis (choice C) is common in newborns due to immature circulation and usually resolves without intervention. Subconjunctival hemorrhage (choice D) is also a common benign finding in newborns and usually resolves without treatment.
A nurse is providing prenatal teaching to a client who practices a vegan diet and is trying to increase intake of vitamin B12. Which of the following foods should the nurse recommend?
- A. Fortified soy milk
- B. Raw carrots
- C. Fresh citrus fruits
- D. Brown rice
Correct Answer: A
Rationale: The correct answer is A: Fortified soy milk. Soy milk is often fortified with vitamin B12, making it a suitable option for vegans. Vitamin B12 is primarily found in animal products, so vegans need to rely on fortified foods or supplements. Raw carrots (B), fresh citrus fruits (C), and brown rice (D) do not contain significant amounts of vitamin B12 and are not suitable sources for increasing intake. It is important for the nurse to recommend a specific food that is known to be fortified with vitamin B12 to meet the client's dietary needs.
A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client into a hands-and-knees position. Which of the following questions should the nurse ask to evaluate the effectiveness of this intervention?
- A. Does that lessen your suprapubic pain?
- B. Are you feeling relief from your pelvic pressure?
- C. Do your contractions feel further apart?
- D. Has your back labor improved?
Correct Answer: D
Rationale: Rationale: The correct answer is D. In the occipitoposterior position, the fetus's head is pressing against the mother's sacrum, causing intense back pain known as back labor. By asking if the back labor has improved, the nurse can assess if the hands-and-knees position has helped relieve the pressure on the mother's sacrum, indicating effectiveness.
Incorrect Choices:
A: Suprapubic pain is not directly related to the occipitoposterior position or the hands-and-knees position.
B: Pelvic pressure may not necessarily be alleviated by changing positions in occipitoposterior position.
C: Contractions feeling further apart may not directly correlate with the effectiveness of the hands-and-knees position for back labor relief.
A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hr ago. Which of the following findings place the client at risk for postpartum hemorrhage? (Select all that apply.)
- A. Labor induction with oxytocin
- B. Newborn weight 2.948 kg (6 lb 8 oz)
- C. Vacuum-assisted delivery
- D. History of uterine atony
- E. History of human papillomavirus
Correct Answer: A,C,D
Rationale: The correct answers are A, C, and D.
A: Labor induction with oxytocin can lead to uterine hyperstimulation, increasing the risk of postpartum hemorrhage.
C: Vacuum-assisted delivery can cause trauma to the birth canal, leading to increased risk of bleeding.
D: A history of uterine atony indicates a weakened ability of the uterus to contract post-delivery, increasing the risk of hemorrhage.
B: Newborn weight is not directly related to postpartum hemorrhage risk.
E: History of human papillomavirus does not directly impact postpartum hemorrhage risk.