What is the priority nursing action when shoulder dystocia is encountered during delivery?

Correct Answer: C

Rationale: In the scenario of encountering shoulder dystocia during delivery, the priority nursing action is to perform the McRoberts maneuver, which involves hyperflexing the mother's legs tightly against her abdomen to help dislodge the impacted shoulder of the baby. This maneuver aims to increase the pelvic outlet diameter, facilitating the passage of the baby's shoulder and preventing further complications such as brachial plexus injury or fetal hypoxia. Applying fundal pressure (option A) is contraindicated in shoulder dystocia situations as it can worsen the impaction of the shoulder and lead to further complications. Calling for additional assistance (option B) is important but should not precede the immediate intervention of the McRoberts maneuver. Encouraging the mother to push harder (option D) is not the appropriate action as forceful pushing can exacerbate the shoulder impaction. Educationally, understanding the priority interventions in obstetrical emergencies like shoulder dystocia is crucial for nurses caring for laboring women. Proper knowledge and quick, decisive actions can significantly impact maternal and neonatal outcomes during childbirth. Practicing these scenarios through simulations and staying updated on evidence-based practices are essential for nurses working in maternal newborn care settings.

Correct Answer: C

Rationale: In supporting a mother planning to formula-feed her newborn, option C, providing information about formula preparation, is the correct choice. This is essential as it ensures the mother understands how to properly prepare and store formula to meet her baby's nutritional needs and prevent contamination or improper mixing. Option A is incorrect because discouraging frequent feeding can lead to underfeeding and compromise the newborn's nutritional intake. Option B, recommending holding the baby during feeding, is a good practice for bonding but is not directly related to supporting formula feeding. Option D, advising limiting formula feeding to once daily, is incorrect as newborns typically need to feed more frequently to meet their nutritional requirements. Educationally, it is crucial for nurses to provide accurate and detailed information about formula feeding to empower mothers in making informed decisions regarding their newborn's nutrition. By emphasizing proper formula preparation, nurses can help ensure the health and well-being of both the newborn and the mother.

Correct Answer: C

Rationale: The postpartum client who requires further assessment is the G4P4 who had 4 saturated pads during the last 12 hours. This indicates excessive postpartum bleeding, which is abnormal and could potentially be a sign of postpartum hemorrhage. It is crucial to closely monitor and assess the client's vital signs, uterine tone, and overall well-being to prevent any complications related to excessive bleeding. Prompt intervention and medical attention may be necessary to address the postpartum hemorrhage and ensure the client's safety and well-being.

Correct Answer: A

Rationale: Pitocin is a medication commonly used to induce or augment labor by stimulating uterine contractions. It is critical for the nurse to monitor the client closely for potential adverse effects. Fetal distress is a serious concern when Pitocin is being administered. A fetal heart rate of 180 beats per minute without variability may indicate fetal distress due to uteroplacental insufficiency. This is a sign of fetal hypoxia and warrants immediate intervention, including stopping the infusion of Pitocin, repositioning the mother, administering oxygen, and notifying the healthcare provider. It is crucial for the nurse to act promptly to ensure the safety and well-being of both the fetus and the mother.

Correct Answer: A

Rationale: In the scenario of shoulder dystocia during the delivery of a macrosomic fetus, the appropriate action for the nurse to assist would be to help the woman into the McRoberts maneuver. The McRoberts maneuver involves flexing the mother's thighs tightly against her abdomen to flatten the pelvis, allowing for more space to maneuver the baby's shoulder out from behind the pubic bone. This maneuver is often effective at resolving shoulder dystocia without the need for additional interventions such as a cesarean section or fundal pressure. It is a recommended initial step in managing shoulder dystocia and has been shown to be successful in many cases.