Physiological Integrity Q 22
A vaginal exam reveals a footling breech presentation. The nurse should take which of the following actions at this time?
A. Anticipate the need for a Caesarean section
B. Apply the fetal heart monitor
C. Place the client in Genupectoral position
D. Perform an ultrasound exam
Correct Answer: B. Apply the fetal heart monitor
Applying a fetal heart monitor is the correct action at this time. Fetal heart sounds are heard high in the abdomen in breech presentation. Be certain to monitor the FHR and uterine contractions continuously to detect fetal distress early and provide prompt intervention.
Option A: In a breech birth, the birth of the head is the most dangerous part because a loop of umbilical cord that has passed down alongside the head may be compressed. Intracranial hemorrhage is another danger of breech birth because of the pressure changes that has occurred spontaneously. There is no need to prepare for a Caesarean section because vaginal delivery is still possible.
Option C: It is unnecessary to place the client in Genupectoral position (knee-chest). An infant born from a frank breech position usually extends his or her legs continuously during the first 2 or 3 days of life, so be sure to point out to the parents that this is normal.
Option D: There is no need for an ultrasound based on the finding. An anesthesiologist and a pediatrician should be immediately available for all vaginal breech deliveries. A pediatrician is needed because of the higher prevalence of neonatal depression and the increased risk for unrecognized fetal anomalies. An anesthesiologist may be needed if intrapartum complications develop and the patient requires general anesthesia.