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The primigravida client has been pushing for 2 hours when the infant’s head emerges. The infant fails to deliver, and the obstetrician states that the turtle sign has occurred. Which should be the nurse’s interpretation of this information?
- A. There is cephalopelvic disproportion.
- B. The infant has a shoulder dystocia.
- C. The infant’s position is occiput posterior.
- D. The infant’s umbilical cord is prolapsed.
Correct Answer: B
Rationale: The “turtle sign” occurs when the infant’s head suddenly retracts back against the mother’s perineum after emerging from the vagina, resembling a turtle pulling its head back into its shell. This head retraction is caused by the infant’s anterior shoulder being caught on the back of the maternal pubic bone (shoulder dystocia), preventing delivery of the remainder of the infant. Cephalopelvic disproportion occurs when the head is too large to fit through the client’s pelvis. Fetal descent ceases, and infant’s head would not emerge. Persistent occiput posterior results in prolonged pushing; however, once the head is born, the remainder of the birth occurs without difficulty. A cord prolapse occurs when the umbilical cord enters the cervix before the fetal presenting part and is considered a medical emergency.
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The client, who is Chinese American and pregnant, is receiving nutritional counseling about the need for increased amounts of calcium in her diet. Which response by the nurse is most helpful when the client states she does not consume any dairy products?
- A. “Tell me how you perceive dairy products in your culture.”
- B. “Try having a glass of soy milk at each meal and at bedtime.”
- C. “Tell me about your intake of fortified tofu and leafy green vegetables.”
- D. “Rice milk fortified with calcium and nettle tea are good calcium choices.”
Correct Answer: C
Rationale: Assessing the client’s intake of calcium-rich foods is the best response. Both fortified tofu and leafy green vegetables are high in calcium and are common foods consumed in the Chinese American diet. Although asking about the client’s perception of dairy products shows cultural sensitivity, the client has already stated she does not consume these. This statement is not the most helpful regarding helping the client to increase calcium intake in her diet. The nurse is making a recommendation without further assessing the client’s dietary preferences. Soy milk should be calcium fortified; yet, according to research the calcium content can be as much as 85 percent less than the amount indicated on the product label. Both rice milk fortified with calcium and nettle tea are sources of calcium; however, the nurse is making an assumption that the client consumes these beverages.
The experienced nurse instructs the new nurse that a vaginal examination should not be performed on the newly admitted client with possible grade 3 abruptio placentae. Which illustration shows the new nurse’s thinking about the uterus of the client with the grade 3 abruptio placentae?
- A. Illustration 1
- B. Illustration 2
- C. Illustration 3
- D. Illustration 4
Correct Answer: D
Rationale: Illustration 4 shows severe grade 3 abruptio placentae. More than 50% of the placenta separates with concealed hemorrhage. Illustration 1 shows complete placenta previa and not abruptio placentae. Illustration 2 shows partial placenta previa and not abruptio placentae. Illustration 3 shows mild grade 1 abruptio placentae. Less than 15% of the placenta separates with concealed hemorrhage.
The pregnant client presents to the ED with a large amount of painless, bright red bleeding. She looks to be about 30 to 34 weeks pregnant based on her uterine size. She speaks limited English and is unable to communicate with the staff. Which actions should the nurse take? Select all that apply.
- A. Call for an interpreter for this client.
- B. Establish an intravenous access.
- C. Auscultate for fetal heart tones.
- D. Place the client into a lithotomy position.
- E. Perform a digital pelvic examination.
Correct Answer: A,B,C
Rationale: The nurse should call for an interpreter so that the client is able to communicate. An IV access should be performed by the nurse to administer any needed medications. Auscultating FHT will provide information about fetal well-being. Positioning the client in a lithotomy position can cause abdominal pain, and there is no indication that birth is imminent. The pregnant client who presents in later pregnancy should never have a digital pelvic examination because this could cause additional bleeding, especially if she has placenta previa.
On the basis of the health history data, how should the nurse record the client's pregnancy status on the prenatal records?
- A. Multipara
- B. Primipara
- C. Primigravida
- D. Multigravida
Correct Answer: C
Rationale: A primigravida is a woman pregnant for the first time, which matches the client's status of being possibly 2 months pregnant with no prior pregnancies.
The nurse is assessing the laboring client who is morbidly obese. The nurse is unable to determine the fetal position. Which action should be performed by the nurse to obtain the most accurate method of determining fetal position in this client?
- A. Inspect the client’s abdomen.
- B. Palpate the client’s abdomen.
- C. Perform a vaginal examination.
- D. Perform transabdominal ultrasound.
Correct Answer: D
Rationale: Real-time transabdominal ultrasound (US) is the most accurate assessment measure to determine the fetal position and is frequently available in the birthing setting. US images may be used to assess fetal lie, presentation, and position in the morbidly obese client. Inspection of the abdomen can be used to determine fetal position, but because the client is obese, this is not the most accurate method. Palpation of the abdomen can be used to determine fetal position, but because the client is obese, this is not the most accurate method. Vaginal examination can be used to determine fetal position, but because the client is obese, this is not the most accurate method.