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The nurse is assisting the primary care provider (PCP) with a vacuum-assisted delivery because of a prolonged second stage of labor.
The nurse will inform the PCP when which guideline of the procedure is met?

A.

Extension of the episiotomy is performed.

B.

Signs of fetal compromise have resolved.

C.

The "three-pull" rule has been achieved.

D.

Patient is under full anesthesia status.

E.

Patient is under full anesthesia status.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Extension of the episiotomy is not a guideline for vacuum-assisted delivery. Episiotomy extension is considered based on perineal conditions during delivery, not as a primary

guideline for vacuum procedures.

 

Choice B rationale

Signs of fetal compromise resolving is critical for fetal safety but isn't specific to the guidelines for a vacuum-assisted delivery. Continuous fetal monitoring assesses for compromise,

not just vacuum application.

 

Choice C rationale

The "three-pull" rule refers to the number of attempts allowed with the vacuum to avoid excessive force and trauma. This guideline ensures safety during the procedure, preventing

overuse of vacuum pressure.

 

Choice D rationale

Full anesthesia status is unrelated to the guidelines for vacuum-assisted delivery. Anesthesia choices depend on patient and procedural needs, but aren't a guideline criterion for

vacuum use.

 


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View Related questions

Correct Answer is B

Explanation

Choice A rationale

Swaddling provides warmth but doesn't address jitteriness, which may be due to hypoglycemia.

Choice B rationale

Jitteriness in a newborn can indicate hypoglycemia. Prompt glucose assessment is crucial for early detection and management.

Choice C rationale

Feeding could help with glucose levels, but without knowing the glucose status, it might not be the immediate priority.

Choice D rationale

Routine medications are important but not as urgent as addressing possible hypoglycemia in a jittery baby.

Correct Answer is D

Explanation

Choice A rationale

A respiratory rate of 18 breaths/min is normal and does not indicate magnesium toxicity or the need for calcium gluconate.

Choice B rationale

Urinary output of 30 mL/hr is within the acceptable range and does not suggest magnesium toxicity. This indicates adequate renal function.

Choice C rationale

Patellar reflexes rated at one indicate mild hyporeflexia, which can be a side effect of magnesium sulfate but does not necessitate immediate intervention.

Choice D rationale

Serum magnesium level of 10 mg/dL is significantly elevated, indicating magnesium toxicity. Calcium gluconate is the antidote for magnesium toxicity and should be administered

promptly to prevent severe complications.

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