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
Checking for ketones in urine is related to metabolic conditions like diabetic ketoacidosis, not directly relevant to the immediate care of an eclamptic client.
Choice B rationale
Padding the bed rails and headboard helps prevent injury during seizures, which is crucial in managing a client with eclampsia.
Choice C rationale
Providing visual and auditory stimulation can increase the risk of further seizures in an eclamptic client. Reducing stimulation is usually recommended.
Choice D rationale
Placing the bed in the high Fowler's position is not appropriate for managing a client post-seizure. The priority is ensuring airway patency and preventing injury.
Correct Answer is A
Explanation
Choice A rationale
Postpartum psychosis is a serious mental health condition that can result in delusions and hallucinations. These symptoms increase the risk of harm to the infant, so it's essential that
the mother is not left alone with the baby to ensure both their safety.
Choice B rationale
Symptoms of postpartum psychosis typically last longer than one week and require medical intervention, contrary to what is stated in this choice. Treatment usually involves
antipsychotics, mood stabilizers, and sometimes hospitalization.
Choice C rationale
Clinical response to medications can be significant in many cases, and early and aggressive treatment often leads to improvement. This statement is inaccurate and does not reflect
the current understanding of postpartum psychosis treatment.
Choice D rationale
While monitoring vital signs is essential, it is not as critical as ensuring the infant's safety given the mother’s severe mental condition. The focus should be on psychiatric
management and safety protocols rather than routine vitals alone.