Difficulty: Medium
Average Score: 66%
Simulated
Passage / Scenario
A client who is in the second stage of labor with retraction of the fetal head against the maternal perineumA nurse is assisting with the care of a client who is in the second stage of labor. The nurse observes retraction of the fetal head against the maternal perineum as the head is birthed. Which of the following actions should the nurse take?
Correct answer
A
Rationale
Retraction signals shoulder delivery, requiring preparation to facilitate a safe birth.