The nurse is caring for a client with gestational diabetes mellitus during the second stage of labor. After birth of the head, the nurse notes retraction of the fetal head against the maternal perineum. Which action should the nurse anticipate?

Question

The nurse is caring for a client with gestational diabetes mellitus during the second stage of labor.  After birth of the head, the nurse notes retraction of the fetal head against the maternal perineum.  Which action should the nurse anticipate?

Quizplus · Accepted Answer

11ecbb05_cc0e_dfd1_b433_9df64936c7bd_MD0009_00 Shoulder dystocia is an obstetrical emergency in which the fetal head emerges but the anterior shoulder remains wedged behind the maternal symphysis pubis. The nurse may initially observe the fetal head retracting back toward the maternal perineum after birth of the head (ie, turtle sign). The condition is frequently associated with macrosomia (fetal weight >8 lb 13 oz [4000 g]) secondary to gestational diabetes mellitus. However, the occurrence of shoulder dystocia is unpredictable and may be related to maternal factors, such as suboptimal pelvic shape, obesity, or short stature, rather than fetal size. The nurse's primary responsibilities during shoulder dystocia include performing the McRoberts maneuver (ie, sharp flexion of maternal thighs toward abdomen to widen space between pubic bone and sacrum) and applying suprapubic pressure (ie, downward pressure applied to maternal pubic bone to dislodge fetal shoulder) (Option D). (Option A) Administering a tocolytic agent to stop contractions or relax the uterus is not recommended and does not resolve shoulder dystocia. (Option B) Fundal pressure is contraindicated, as it may wedge the fetal shoulder further into the symphysis pubis or cause uterine rupture. (Option C) Application of a vacuum extractor is contraindicated because it may further wedge the fetal shoulder into the symphysis pubis, increasing the risk for brachial plexus injury. Educational objective: Shoulder dystocia occurs when the fetal head emerges but the anterior shoulder remains wedged behind the maternal symphysis pubis. The nurse should be prepared to perform McRoberts maneuver and apply suprapubic pressure.

The Nurse Is Caring for a Client with Gestational Diabetes