A nurse is assisting with the care of a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse take first?
Prepare the client for an emergency cesarean birth.
Explain to the client what is happening.
Cover the cord with a sterile, moist saline dressing.
Place the client in a knee-chest or Trendelenburg position.
The Correct Answer is D
The correct answer is choice d. Place the client in a knee-chest or Trendelenburg position.
Choice A rationale:
Preparing the client for an emergency cesarean birth is important, but it is not the immediate first action. The priority is to relieve pressure on the umbilical cord to prevent fetal hypoxia.
Choice B rationale:
Explaining to the client what is happening is important for communication and reassurance, but it is not the immediate first action. Immediate physical intervention is required to prevent harm to the fetus.
Choice C rationale:
Covering the cord with a sterile, moist saline dressing is a necessary step to prevent the cord from drying out and to reduce infection risk, but it should be done after repositioning the client to relieve pressure on the cord.
Choice D rationale:
Placing the client in a knee-chest or Trendelenburg position helps to relieve pressure on the umbilical cord, which is crucial to maintain fetal oxygenation. This is the immediate first action to take in this emergency situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
The umbilical cord typically contains two arteries and one vein. Arteries carry oxygen-depleted blood and waste products from the fetus to the placenta for removal, while the vein carries oxygenated blood and nutrients from the placenta to the fetus. This arrangement is essential for maintaining proper fetal circulation during pregnancy.
Choice B rationale:
This choice is incorrect because the umbilical cord usually contains two arteries and one vein, not just one artery and one vein. Having only one artery could indicate a potential vascular abnormality or congenital issue that may require further investigation or medical attention.
Choice C rationale:
This is the correct answer. The umbilical cord usually contains two arteries and one vein. The presence of two arteries allows for the efficient removal of waste products and carbon dioxide from the fetus, while the single vein delivers essential nutrients and oxygen to support the baby's growth and development.
Choice D rationale:
This choice is incorrect as it states two veins and one artery, which is not the typical configuration of blood vessels in the umbilical cord. Having two veins and one artery would disrupt fetal circulation and hinder proper nutrient and waste exchange between the fetus and the placenta.
Correct Answer is D
Explanation
Choice A rationale:
Vaginal hematoma is not a common complication in the 4th stage of labor. This stage primarily involves the recovery and stabilization of the mother after delivery.
Choice B rationale:
Hypoglycemia is not a typical complication in the 4th stage of labor. While blood glucose levels might be monitored during labor, the risk of hypoglycemia is generally higher in neonates, especially if the mother has diabetes.
Choice C rationale:
Chorioamnionitis is an infection of the fetal membranes and amniotic fluid, typically diagnosed during labor or shortly after delivery. It is not specific to the 4th stage of labor.
Choice D rationale:
Uterine hemorrhage is the most significant concern during the 4th stage of labor, also known as the "postpartum”. or "recovery”. stage. It refers to excessive bleeding from the site where the placenta detached. This bleeding can be life-threatening if not managed promptly.
Choice E rationale:
Dehiscence is the separation of surgical incisions, which is not a common complication during the 4th stage of labor.
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