A nurse is assisting with the delivery of a client who has a breech presentation.
The nurse notices that the umbilical cord is protruding from the vagina.
Which of the following actions should the nurse take first?
Apply pressure to the presenting part with gloved fingers.
Place the client in Trendelenburg position
Administer oxygen via face mask at 10 L/min.
Clamp and cut the umbilical cord
The Correct Answer is A
The correct answer is choice A. Apply pressure to the presenting part with gloved fingers. This is because applying pressure can prevent further compression of the umbilical cord and reduce the risk of fetal hypoxia (lack of oxygen) . The umbilical cord can be flattened or twisted during delivery, which can cause nerve or brain damage .
Choice B is wrong because placing the client in Trendelenburg position (head down and feet up) may not be enough to relieve the cord compression and may cause discomfort or respiratory distress for the client.
Choice C is wrong because administering oxygen may not improve the fetal oxygenation if the cord is severely compressed.
Oxygen administration may also delay the urgent delivery of the baby.
Choice D is wrong because clamping and cutting the umbilical cord will cut off the fetal blood supply and oxygenation.
This can lead to fetal death or severe brain injury.
Normal ranges for umbilical cord pH are 7.18 to 7.38 for arterial blood and 7.28 to 7.45 for venous blood.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. Apply pressure to the presenting part with gloved fingers.This is because applying pressure can prevent further compression of the umbilical cord and reduce the risk of fetal hypoxia (lack of oxygen).The umbilical cord can be flattened or twisted during delivery, which can cause nerve or brain damage.
Choice B is wrong because placing the client in Trendelenburg position (head down and feet up) may not be enough to relieve the cord compression and may cause discomfort or respiratory distress for the client.
Choice C is wrong because administering oxygen may not improve the fetal oxygenation if the cord is severely compressed.
Oxygen administration may also delay the urgent delivery of the baby.
Choice D is wrong because clamping and cutting the umbilical cord will cut off the fetal blood supply and oxygenation.
This can lead to fetal death or severe brain injury.
Normal ranges for umbilical cord pH are 7.18 to 7.38 for arterial blood and 7.28 to 7.45 for venous blood.
Correct Answer is C
Explanation
The correct answer is choice C. Cord prolapse is more likely to occur in clients who have oligohydramnios.
Oligohydramnios is a condition where there is too little amniotic fluid around the fetus.This can cause the umbilical cord to slip down into the cervix and vagina ahead of the baby during delivery.This can cut off the blood and oxygen supply to the baby and cause fetal distress.
Choice A is wrong because cord prolapse is more likely to occur in clients who have aplacenta previa, not a low-lying placenta.
Placenta previa is a condition where the placenta covers the cervix partially or completely.This can prevent the baby from descending into the pelvis and leave more space for the cord to prolapse.
Choice B is wrong because cord prolapse is more likely to occur in clients who have anon-vertex presentation, such as breech or transverse lie, not a vertex presentation.
A non-vertex presentation means that the baby’s head is not pointing down towards the birth canal.This can result in a smaller or irregularly shaped presenting part that does not fit snugly into the pelvis and allows the cord to slip past it.
Choice D is wrong because cord prolapse is more likely to occur in clients who have amultiple pregnancy, not a singleton
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