A nurse is assisting with the care of a client in active labor. The nurse observes clear fluid and a loop of pulsating umbilical cord outside the client's vagina. Which of the following actions should the nurse perform first?

Assist in initiating IV access and administering IV fluid bolus

Call for assistance immediately

Apply finger pressure to the presenting part

Administer oxygen at 10 L/min via a nonrebreather

Answer and Explanation

The Correct Answer is B

A. Assist in initiating IV access and administering IV fluid bolus: While IV fluids may be needed, the priority in this case is to address the umbilical cord prolapse, which poses an immediate risk to the baby.

B. Call for assistance immediately: Cord prolapse is an obstetric emergency that requires immediate assistance to prevent fetal hypoxia. Rapid response is crucial to save the baby.

C. Apply finger pressure to the presenting part: Although applying pressure to relieve compression on the cord is necessary, the first action should be to summon help to manage the emergency.

D. Administer oxygen at 10 L/min via a nonrebreather: Oxygen is important to improve maternal and fetal oxygenation, but calling for help is the immediate priority in this life-threatening situation.

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Correct Answer is C

Explanation

A. Duration: Duration refers to how long a single contraction lasts from start to finish, not the time between contractions.

B. Acme: Acme refers to the peak of the contraction, not the time between contractions.

C. Frequency: Frequency refers to the time from the beginning of one contraction to the beginning of the next contraction.

D. Onset: Onset refers to the start of an individual contraction, not the interval between contractions.

A. An artifact on the printout is very common B. Accurate information regarding FHR variability is not possible C. It cannot provide data about the uterine resting tone D. It is invasive and increases the risk for uterine infection

Correct Answer is A

Explanation

A. An artifact on the printout is very common. Artifacts are more common with external fetal monitoring, not internal fetal monitoring.

B. Accurate information regarding FHR variability is not possible. Internal fetal monitoring provides more accurate information about fetal heart rate (FHR) variability compared to external monitoring.

C. It cannot provide data about the uterine resting tone. Internal monitoring can measure the uterine resting tone more accurately than external methods.

D. It is invasive and increases the risk for uterine infection. Internal fetal monitoring requires inserting a device into the uterus, making it invasive and increasing the risk of infection.

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A nurse is assisting with the care of a client in active labor. The nurse observes clear fluid and a loop of pulsating umbilical cord outside the client's vagina. Which of the following actions should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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