A nurse is caring for a client who is in labor and has spontaneous rupture of membranes. The nurse notes that the umbilical cord is protruding from the client's vagina. After calling for help, which of the following actions should the nurse take first?
Use fingers to exert upward pressure on the presenting part
Administer a tocolytic medication
Wrap the cord in a sterile towel and moisten with warm sterile normal saline
Apply oxygen via facemask to the client
The Correct Answer is A
A. Use fingers to exert upward pressure on the presenting part
The priority in the case of a prolapsed umbilical cord is to relieve pressure on the cord to maintain blood flow to the fetus. The nurse should use sterile-gloved fingers to lift the presenting part of the fetus off the prolapsed cord. This action helps prevent compression of the umbilical cord, which could lead to fetal hypoxia and distress.
B. Administer a tocolytic medication: Tocolytic medications are used to inhibit uterine contractions. While tocolytics might be used in certain situations, the immediate concern with a prolapsed cord is to relieve pressure on it to maintain fetal blood flow.
C. Wrap the cord in a sterile towel and moisten with warm sterile normal saline: While covering the cord with a sterile towel and moistening it can help prevent drying and protect the cord, it is not the first priority. The primary concern is relieving pressure on the cord to prevent fetal compromise.
D. Apply oxygen via facemask to the client: Oxygen administration is important in managing fetal distress, but it is not the first action to take in the case of a prolapsed umbilical cord. The priority is to relieve pressure on the cord to maintain fetal oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A client who reports lochia rubra requiring changing perineal pads every 3 hr: Lochia rubra is the normal discharge during the early postpartum period. Changing perineal pads every 3 hours is within the expected range and does not warrant immediate notification of the provider.
B. A client who has a urinary output of 300 mL in 8 hr: Although the urinary output is relatively low, the information provided is not sufficient to conclude that this is abnormal. Further assessment is needed, and this finding alone may not be an emergency. However, it should be monitored.
C. A client who is receiving magnesium sulfate and has absent deep tendon reflexes: Absent deep tendon reflexes can be a sign of magnesium toxicity. Magnesium sulfate is used for various indications, such as preeclampsia or eclampsia, but it has a narrow therapeutic range. Absent deep tendon reflexes suggest the need for immediate attention and notification of the provider.
D. A client who reports abdominal cramping during breastfeeding: Abdominal cramping during breastfeeding is a common postpartum symptom associated with uterine contractions. It is a normal physiological response and does not require immediate notification of the provider.
Correct Answer is C
Explanation
A. Intense contractions lasting 45 to 60 seconds: Intense contractions within a normal duration are typical during the active phase of labor. This finding does not necessarily warrant immediate reassessment but rather ongoing monitoring.
B. A sense of excitement and warm, flushed skin: A sense of excitement and warm, flushed skin may be associated with the transition phase of labor and is not necessarily a cause for immediate concern.
C. An urge to have a bowel movement during contractions: This is the correct answer. The urge to have a bowel movement may indicate fetal descent and the need to assess for full cervical dilation. It could signal the need for imminent delivery, and the nurse should promptly assess the client's cervix and notify the healthcare provider.
D. Progressive sacral discomfort during contractions: Discomfort, including sacral discomfort, is common during labor. Progressive sacral discomfort may be associated with the normal progression of labor and is not a reason for immediate reassessment.
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