A nurse is assisting with the delivery of a client who has a prolapsed umbilical cord.
Which of the following interventions should the nurse perform to relieve cord compression until delivery?
Elevate the presenting part with a sterile gloved hand
Push the cord back into the vagina with gentle pressure
Clamp and cut the cord as quickly as possible
Wrap the cord loosely around the fetal neck
The Correct Answer is A
The correct answer is choice A. Elevate the presenting part with a sterile gloved hand. This intervention helps to relieve cord compression until delivery by preventing the fetus from pushing down on the cord . The umbilical cord is the lifeline of the fetus and any compression can cause fetal hypoxemia and distress .
Choice B is wrong because pushing the cord back into the vagina with gentle pressure can cause more damage to the cord and increase the risk of infection .
Choice C is wrong because clamping and cutting the cord as quickly as possible will cut off the fetal blood supply and oxygenation .
Choice D is wrong because wrapping the cord loosely around the fetal neck can cause strangulation and compromise fetal circulation .
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. Place the client in a knee-chest position.This is because this position can reduce the pressure of the fetal presenting part on the prolapsed cord and improve fetal oxygenation.The nurse should also notify the provider and prepare for an emergency cesarean delivery, but this is not the first action to take.
Choice A is wrong because applying warm saline-soaked gauze to the exposed cord can prevent drying and atrophy of the cord, but it does not relieve cord compression.
Choice C is wrong because administering oxygen via face mask at 10 L/min can increase maternal oxygen saturation and fetal oxygen delivery, but it does not address the cause of cord prolapse.
Choice D is wrong because notifying the provider and preparing for an emergency cesarean delivery is a necessary action, but it is not the first priority.The nurse should first try to relieve cord compression by placing the client in a knee-chest position.
Correct Answer is D
Explanation
The correct answer is choice D.Severe variable decelerations indicate cord compression and hypoxemia in a fetus with a prolapsed umbilical cord.Variable decelerations are abrupt decreases in fetal heart rate below the baseline, usually associated with uterine contractions.Severe variable decelerations are defined as having a nadir of less than 70 beats per minute or lasting longer than 60 seconds.
Choice A is wrong because episodic accelerations are transient increases in fetal heart rate above the baseline, usually indicating fetal well-being.
Choice B is wrong because fibrillation is an irregular and rapid contraction of the atria of the heart, which is not a normal fetal heart rate pattern.
Choice C is wrong because moderate tachycardia is a slightly elevated fetal heart rate above the normal range of 110 to 160 beats per minute, which may be caused by maternal fever, fetal infection, fetal anemia, or fetal hypoxia.
However, moderate tachycardia alone does not indicate cord compression and hypoxemia.
The normal range of fetal heart rate is 110 to 160 beats per minute.
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