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?
Extension of the episiotomy is performed.
Signs of fetal compromise have resolved.
The "three-pull" rule has been achieved.
Patient is under full anesthesia status.
Patient is under full anesthesia status.
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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Correct Answer is B
Explanation
Choice A rationale
Retained tissue can cause postpartum hemorrhage, but with a firm uterus and no other signs of retained placenta, this is less likely the cause here.
Choice B rationale
Trauma is the most likely cause of increased bleeding in this scenario. The prolonged oxytocin induction and macrosomic infant suggest a higher risk of lacerations or uterine atony
despite the firm uterus.
Choice C rationale
Thrombin disorders cause bleeding due to clotting issues. However, this patient shows signs of active bleeding and clotting, making this less likely.
Choice D rationale
Uterine atony, indicated by a soft, boggy uterus, is a common cause of postpartum hemorrhage, but in this case, the uterus is firm, so it's less likely to be the cause.
Correct Answer is C
Explanation
Choice A rationale
While it’s true that increased discomfort is expected with twins due to additional physical strain and space constraints, this alone is not sufficient reassurance. It is vital to assess for
signs of preterm labor or other complications.
Choice B rationale
Performing a digital cervical examination is a valid approach to checking for dilation, but this action must be carefully considered based on other signs and symptoms presented by
the patient. The focus here is on ensuring the absence or presence of labor, which might require hospital assessment.
Choice C rationale
Sending the patient to the hospital to be checked for possible signs of labor ensures that professional monitoring and interventions can occur if labor is confirmed. This action
prioritizes safety, given the increased risk of complications with twin pregnancies and the advanced gestation of 37 weeks.
Choice D rationale
Assuring the patient of the absence of contractions after an examination might provide temporary relief, but it does not address the possibility of other signs of labor or complications
that may require more comprehensive hospital assessment.