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.
Administer a fluid bolus of 500 mL.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1500"]
Explanation
Step 1 is. (500 mL ÷ 20 min) × 60 min/hr = 1500 mL/hr. Answer: 1500 mL/hr.
Correct Answer is B
Explanation
Choice A rationale
Telling the child that you're glad the mother explained the procedure doesn't provide the child with an opportunity to express their understanding or concerns. It is important to engage the child directly to understand what they know and how they feel about the operation, rather than relying solely on what the parent has communicated.
Choice B rationale
Asking the child to explain what an operation is allows the nurse to gauge the child's understanding and provides an opportunity to correct any misconceptions. This approach also encourages open communication and helps the child feel more involved and informed about their own care, which can reduce anxiety.
Choice C rationale
Reassuring the child that the hospital staff will take very good care of them is comforting, but it doesn't address the child's need for information and understanding about the operation. While it's important to provide reassurance, the primary focus should be on ensuring the child comprehends what will happen.
Choice D rationale
Directly asking the child if they are scared might lead to a yes or no answer, and doesn't necessarily encourage them to share their specific fears or concerns. It is more effective to ask open-ended questions that allow the child to express their feelings in more detail, which can then be addressed by the nurse.
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