The nurse has been caring for a primiparous patient who is suspected of carrying a macrosomic infant
Pushing appears to have been effective so far; however, as soon as the head is born, it retracts against the perineum much like a turtle's head drawing into its shell. In evaluating the labor progress so far, the nurse is aware that this is normal with large infants and extra pushing efforts by the mother may be necessary. Is this statement true or false? Indicate whether the statement is true or false
F
This is often referred to as the "turtle sign" and is an indication of shoulder dystocia.
Delayed or difficult birth of the shoulders may occur if they become impacted above the
maternal symphysis pubis. This complication of birth requires immediate intervention
because the umbilical cord is compressed and the chest cannot expand within the vagina.
Any of several methods may be employed to relieve the impacted shoulders. Shoulder
dystocia is unpredictable and although more common in large infants, can occur with a
baby of any weight.
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The nurse is attempting to assess the femoral pulse in a patient who is obese. Which of these actions would be most appropriate?
a. The patient is asked to assume a prone position. b. The patient is asked to bend his or her knees to the side in a froglike position. c. The nurse firmly presses against the bone with the patient in a semi-Fowler position. d. The nurse listens with a stethoscope for pulsations; palpating the pulse in an obese person is extremely difficult.
Which nursing intervention would be the highest priority in evaluating a patient with peritonitis from a ruptured appendix?
a. Assessment of severity, location, and duration of pain b. Assessment of vital signs c. Preventing wound infection d. Promoting balanced nutrition
A patient is being discharged home after liver transplantation. The patient still has a hepatic artery catheter in place. What is this hepatic artery catheter for?
A) To monitor portal hypertension B) To give immunosuppressive drugs during the first weeks after transplantation C) To monitor vascular changes in the hepatic system D) To deliver a continuous chemotherapeutic dose until completed
The patient you are caring for has been diagnosed with AIDS complicated by chronic diarrhea. What nursing intervention would be appropriate for this patient?
A) Keep perianal area free of discharge. B) Give cholinergic medications as ordered. C) Make sure the patient eats at least two servings of raw fruit each day. D) Feed small, frequent meals to prevent abdominal distention.