A client who is in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the perineum.
Which action should the nurse perform first?

Place the client in Trendelenburg.

Notify the operating room team.

Administer oxygen via face mask.

Administer a fluid bolus of 500 mL.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Placing the client in Trendelenburg position is the first action as it helps to relieve pressure off the umbilical cord by using gravity to shift the fetus away from the pelvis. This position helps to prevent cord compression and maintain blood flow to the fetus.

Choice B rationale

Notifying the operating room team is important but should be done after immediately addressing the umbilical cord prolapse to prevent fetal hypoxia. Initial physical intervention takes priority.

Choice C rationale

Administering oxygen via face mask is beneficial for the mother and fetus but is not the immediate first action. Positioning the client to relieve pressure off the umbilical cord is more urgent.

Choice D rationale

Administering a fluid bolus of 500 mL can help maintain maternal blood pressure, but it is not the first action. The priority is to reposition the client to prevent cord compression.

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Correct Answer is D

Explanation

Choice A rationale

This choice suggests assessing if the child can administer the insulin. While it's important for children with diabetes to learn self-care skills, a 10-year-old may not yet be ready to take on the responsibility of injecting insulin regularly. The child might still rely on parental or caregiver support for this task. Moreover, it does not address the immediate issue of the mother's fear of needles.

Choice B rationale

This choice focuses on assessing the mother's parenting skills. It is not directly related to solving the issue of insulin administration. The mother's fear of needles does not necessarily reflect her overall parenting skills. Assessing parenting skills would not provide a practical solution to the child's need for insulin administration.

Choice C rationale

Encouraging the mother to handle the needles could help overcome her fear, but it might not be effective in the short term. The mother might need time and professional help to deal with her fear of needles. This choice does not provide an immediate solution for the child's need for insulin injections.

Choice D rationale

Asking if the father can help with the injections is a practical and immediate solution. If the father is available and comfortable with handling needles, he can take on the responsibility of administering insulin to the child. This ensures that the child's medical needs are met while giving the mother time to overcome her fear of needles.

A. Which action should the nurse take? B. Cover the lesion with a dressing. C. Obtain blood cultures. D. Prepare for a cesarean section. E. Administer penicillin.

Correct Answer is C

Explanation

Choice A rationale

Covering the lesion with a dressing is not an appropriate action as it will not prevent the transmission of herpes to the newborn. Herpes simplex virus can be transmitted to the neonate during delivery, and covering the lesion does not eliminate the risk.

Choice B rationale

Blood cultures are not indicated for managing active herpes lesions in a client with spontaneous rupture of membranes. This action does not address the immediate risk of transmission of the virus to the newborn.

Choice C rationale

Preparing for a cesarean section is the appropriate action because it reduces the risk of neonatal herpes transmission. Neonatal herpes can lead to severe complications, and a cesarean section is recommended to minimize the risk of exposure to the virus during vaginal delivery.

Choice D rationale

Administering penicillin is not appropriate for treating herpes lesions. Penicillin is an antibiotic effective against bacterial infections, but herpes is caused by a virus. Antiviral medications are required to manage herpes infections.

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A client who is in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the perineum. Which action should the nurse perform first?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes.

Correct Answer is C

Explanation

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A client who is in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the perineum.
Which action should the nurse perform first?