Nokea
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 baby's shoulder is stuck behind the mother's pubic bone. The McRoberts maneuver involves hyperflexing the mother's legs towards her abdomen to enlarge the pelvic outlet, which can help dislodge the shoulder and facilitate delivery. This action can help create more space for the baby to maneuver and be born. Applying pressure to the fundus (A) does not address the mechanical issue of shoulder dystocia. Pressing on the suprapubic area (B) may not provide the necessary space for the baby to be delivered. Moving the client onto their hands and knees (C) may not be as effective as the McRoberts maneuver in this situation.
You may also like to solve these questions
A nurse is caring for a client who is 12 hr postpartum and has a third-degree perineal laceration. The client reports not having a bowel movement for 4 days. Which of the following medications should the nurse administer?
- A. Bisacodyl 10 mg rectal suppository
- B. Magnesium hydroxide 30 mL PO
- C. Famotidine 20 mg PO
- D. Loperamide 4 mg PO
Correct Answer: A
Rationale: A rectal suppository like bisacodyl is appropriate for relieving constipation in a postpartum client with a perineal laceration, as it avoids straining. Loperamide is an antidiarrheal and not indicated here.
What is the recommended method of administering erythromycin ointment to a newborn?
- A. Intramuscular injection
- B. Oral administration
- C. Topical application
- D. Subcutaneous injection
Correct Answer: C
Rationale: The correct answer is C: Topical application. Administering erythromycin ointment to a newborn involves applying it directly to the eyes to prevent neonatal conjunctivitis. This method ensures direct contact with the affected area, allowing for maximum effectiveness while minimizing systemic absorption and potential side effects. Intramuscular or subcutaneous injections are not appropriate for ointment administration, as they are meant for liquid medications. Oral administration would not target the eyes specifically. It is crucial to follow recommended guidelines to ensure the newborn's safety and effective treatment.
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 (p200
- B. Down Syndrome)
- C. Rust-stained urine
- D. Transient circumoral cyanosis
- E. Subconjunctival hemorrhage
Correct Answer: A
Rationale: The correct answer is A: Single palmar creases. This finding may indicate an increased risk for Down Syndrome. It is important to report this to the provider for further evaluation. Single palmar creases are less common and can be a marker for chromosomal abnormalities.
B: Down Syndrome is not a clinical finding but a diagnosis.
C: Rust-stained urine is not typically concerning in a newborn and may be due to uric acid crystals.
D: Transient circumoral cyanosis is common in newborns and usually resolves on its own.
E: Subconjunctival hemorrhage can occur during the birthing process and is usually benign.
Which of the following tests is used to assess fetal lung maturity?
- A. Non-stress test
- B. Biophysical profile
- C. Amniocentesis
- D. Lecithin-sphingomyelin (L/S) ratio
Correct Answer: D
Rationale: The correct answer is D: Lecithin-sphingomyelin (L/S) ratio. This test is used to assess fetal lung maturity by measuring the ratio of two substances found in the amniotic fluid. An L/S ratio greater than 2:1 is indicative of mature fetal lungs. This test is crucial in determining if a baby can breathe adequately after birth. The other choices are incorrect because: A) Non-stress test monitors fetal heart rate and movements, B) Biophysical profile assesses fetal well-being, and C) Amniocentesis is a procedure to collect amniotic fluid for genetic testing.
A nurse is obtaining a 2-hr postprandial blood glucose from a client. Which of the following actions should the nurse take?
- A. Puncture the finger while still damp with antiseptic solution.
- B. Smear the blood onto the reagent strip.
- C. Hold the finger above the heart prior to puncture.
- D. Select the lateral side of the finger for puncture.
Correct Answer: D
Rationale: The correct answer is D: Select the lateral side of the finger for puncture. This is important because the lateral side of the finger has fewer nerve endings, which can reduce pain for the client. Puncturing the finger while still damp with antiseptic solution (choice A) can dilute the blood sample and affect the accuracy of the test. Smearing the blood onto the reagent strip (choice B) can lead to incorrect results due to inadequate blood volume or improper application. Holding the finger above the heart prior to puncture (choice C) can increase blood flow and may result in a higher blood glucose reading. Therefore, selecting the lateral side of the finger for puncture is the most appropriate action to ensure accurate and less painful blood glucose monitoring.