A nurse is assisting with the care of a client who presents to a labor and delivery unit with rapidly progressing labor. Which of the following actions is the priority for the nurse to take?
Supporting the infant during the birth.
Preventing the perineum from tearing.
Cutting the umbilical cord.
Promoting delivery of the placenta.
The Correct Answer is A
Choice A rationale:
Supporting the infant during birth. The priority for the nurse in this situation is to ensure the safe delivery of the baby. By supporting the infant during birth, the nurse can help ensure that the baby is delivered safely and efficiently. This involves assisting the mother in pushing and guiding the baby's head and body as it emerges from the birth canal. The nurse should also be ready to catch the baby and provide immediate care, such as drying and stimulating the baby to breathe if necessary.
Choice B rationale
Preventing the perineum from tearing. While preventing perineal tearing is important, it is not the top priority in this rapidly progressing labor scenario. The immediate concern is the safe delivery of the baby, and if perineal tearing does occur, it can be addressed after the birth.
Choice C rationale
Cutting the umbilical cord. This action is necessary but not the top priority. After the baby is delivered, the nurse should clamp and cut the umbilical cord to separate the baby from the placenta. However, this can wait until the baby is fully delivered and breathing on their own.
Choice D rationale
Promoting delivery of the placenta. Again, while delivering the placenta is important to prevent postpartum haemorrhage, it is not the priority in this scenario. The nurse's immediate focus should be on supporting the infant's delivery and ensuring the baby's well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A, Maternal hypertension.
Choice A rationale:
Maternal hypertension is widely recognized as the most common risk factor for placental abruption. High blood pressure can cause the placenta to detach from the uterine wall, leading to abruption. In summary, while all the listed factors can contribute to the risk of placental abruption, maternal hypertension stands out as the most common cause, supported by multiple health sources. It’s important for nurses to recognize and manage hypertension in pregnant clients to minimize the risk of this serious complication.
Choice B rationale:
While maternal cocaine use is a significant risk factor for placental abruption due to its vasoconstrictive effects, which can compromise the placental blood flow, it is not as common as maternal hypertension.
Choice C rationale:
Maternal cigarette smoking is also a risk factor for placental abruption. Smoking can lead to a variety of complications in pregnancy, including placental problems, but again, it is less common than hypertension as a cause for abruption.
Choice D rationale:
Maternal battering can lead to trauma which may result in placental abruption. However, it is not considered the most common risk factor when compared to maternal hypertension.
Correct Answer is B
Explanation
Choice A rationale:
Choice A, fetal head compression, is not the correct answer in this case. Fetal head compression can cause early decelerations in the FHR, not variable decelerations. Early decelerations are often a result of the fetal head being compressed during contractions and are considered benign and expected during labor.
Choice B rationale:
The correct answer is choice B, which is umbilical cord compression. Variable decelerations of the fetal heart rate (FHR) can occur during labor due to various rationales, and umbilical cord compression is one of the common causes. When the umbilical cord gets compressed, it can briefly reduce or restrict the blood flow and oxygen supply to the fetus, leading to temporary decelerations in the FHR.
Choice C rationale:
Choice C, maternal fever, is also not the correct answer for variable decelerations in FHR. Maternal fever can be a sign of infection, and it may lead to other fetal heart rate abnormalities, such as tachycardia (an increased heart rate), but it is not specifically associated with variable decelerations.
Choice D rationale:
Choice D, polyhydramnios, is not the cause of variable decelerations in this scenario. Polyhydramnios refers to an excessive accumulation of amniotic fluid around the fetus. While it can have implications for pregnancy, it is not directly linked to variable decelerations of the FHR.
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