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 .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
The correct answer is choices A, B and C. These are the risk factors for umbilical cord prolapse that the nurse should include in the teaching.Umbilical cord prolapse is where the umbilical cord descends through the cervix, with (or before) the presenting part of the fetus.It can cause fetal hypoxia and distress by occluding or compressing the blood flow to the fetus.
Choice A is correct because premature rupture of membranes, especially when the presenting part of the fetus is high in the pelvis, can allow the cord to slip down into the cervix and vagina.
Choice B is correct because breech presentation, such as a footling breech, can make it easy for the cord to slip between and past the fetal feet and into the pelvis.
Choice C is correct because polyhydramnios, or excessive amniotic fluid around the fetus, can create more space for the cord to move and prolapse.
Choice D is wrong because post-term pregnancy is not a risk factor for umbilical cord prolapse.Post-term pregnancy can cause other complications such as fetal macrosomia, placental insufficiency and meconium aspiration.
Choice E is wrong because multiple gestation is not a risk factor for umbilical cord prolapse.Multiple gestation can cause other complications such as preterm labor, preeclampsia and fetal growth restriction.
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.
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