Question

A vaginal exam reveals a breech presentation. The nurse should take which of the following actions at this time? A. Prepare the client for a Caesarean section B. Apply the fetal heart monitor C. Place the client in Trendelenburg position D. Perform an ultrasound exam

Short answer

Answer: The most appropriate immediate action is to apply the fetal heart monitor. This will help assess the baby's well-being and guide further actions or interventions.

Step-by-step solution

Understand the Situation

First, let's recognize the situation at hand: A vaginal exam reveals a breech presentation. This means that the baby is positioned to be delivered feet or buttocks first instead of the head, which is the ideal position for safe delivery.

Review the Options

There are four given actions for the nurse to consider: A. Prepare the client for a Caesarean section B. Apply the fetal heart monitor C. Place the client in Trendelenburg position D. Perform an ultrasound exam

Evaluate Each Option

A. Caesarean section: In some cases, a Caesarean section may be recommended for a breech presentation, but not necessarily as the immediate action. It's important to evaluate the baby's condition before deciding to perform a C-section. B. Apply the fetal heart monitor: This is an essential action since it will allow medical staff to monitor the baby's heart rate to assure the baby is not in distress. C. Place the client in Trendelenburg position: This position would involve placing the client with their head down and feet up. While this maneuver may sometimes be used to try and encourage the baby to turn into a better position, it's not the most appropriate immediate action. D. Perform an ultrasound exam: While an ultrasound may give valuable information about the baby's position and overall condition, applying the fetal heart monitor should be prioritized.

Choose the Correct Action

The appropriate action to take in this situation is option B: Apply the fetal heart monitor. This will help assess the baby's well-being and guide further actions or interventions. The other options may be considered later based on the information gathered from the monitor and other clinical assessments.

Key concepts

Understanding Breech Presentation

Breech presentation is a term used in obstetrics to describe a situation where the fetus is positioned in the uterus with the buttocks or feet closest to the birth canal, rather than the head. During pregnancy, health professionals closely monitor the position of the fetus, as the optimal position for birth is headfirst, or cephalic presentation. A breech position can present challenges for vaginal delivery and is associated with higher risks of complications both for the mother and the baby.

In managing breech presentation, several options are available. Sometimes, health care providers may attempt to turn the baby to the proper position in a procedure known as an external cephalic version (ECV). However, if the fetus remains in a breech position and the practitioner considers a vaginal delivery unsafe, a Caesarean section may be planned. It's important to note that not all breech presentations ultimately require surgical delivery; the decision depends on various factors including the type of breech, the size of the baby, the maternal pelvis, and the experience of the healthcare provider.

The Role of Fetal Heart Monitoring

Fetal heart monitoring is a pivotal aspect of prenatal care, especially during labor and delivery. By tracking the heart rate of the fetus, health care providers can gain insight into how well the fetus is coping with the birthing process. Anomalies in the heart rate patterns can indicate fetal distress, necessitating timely intervention to prevent adverse outcomes.

When a breech presentation is identified, applying a fetal heart monitor becomes even more essential, as the risks and stress associated with such deliveries can lead to potential changes in the baby's heart rate. Early detection of any cardiac distress signals allows the medical team to act promptly, which might include performing an emergency Caesarean section if the wellbeing of the fetus is compromised.

Nursing Interventions for Breech Presentation

Nurses play a critical role when it comes to managing breech presentations. Their interventions are directed towards ensuring the safety and comfort of the client, as well as the fetus. Initial nursing interventions include confirming the breech position, usually via a vaginal examination or ultrasound, and then applying fetal heart monitoring to assess the fetus's condition.

Nursing actions may also involve preparing the patient for potential outcomes, including a Caesarean section for delivery. Education and support are fundamental as well, as being diagnosed with a breech presentation can cause anxiety for expectant mothers. Nurses provide explanations on what a breech position entails, discuss possible interventions like ECV, and ensure that the mother understands the monitoring process and potential delivery methods. Throughout this period, the nurse continues to monitor both maternal and fetal wellbeing vigilantly.