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. The client will demonstrate proper bathing of the infant: This goal is more appropriate for later phases of postpartum adjustment when the mother becomes more involved in caring for her infant. During the taking-in phase, the focus is on the mother's own recovery.
B. The client will verbalize appropriate car seat safety: This goal is related to the safety and care of the newborn, and it may be more relevant in the taking-hold phase when the mother becomes more actively involved in caring for her baby.
C. The client will have adequate nutritional intake: This is the correct goal. Adequate nutritional intake is important for the mother's recovery, energy levels, and breastfeeding success. The nurse should assess and promote proper nutrition during the taking-in phase.
D. The client will identify individual family member roles: Family roles and dynamics are more commonly addressed in the postpartum adjustment phase known as the let-go phase, which occurs later as the mother becomes more comfortable and accepting of her new role.
Correct Answer is B
Explanation
A. Firm rigid abdomen: A firm and rigid abdomen is more indicative of uterine hypertonicity or uterine hyperstimulation, which is not typically associated with placenta previa. It may be seen in conditions such as uterine rupture.
B. Painless vaginal bleeding: Placenta previa is a condition where the placenta partially or completely covers the cervix, leading to painless vaginal bleeding. This bleeding occurs because as the cervix begins to dilate and efface in preparation for labor, blood vessels in the placenta may rupture, causing bleeding. Importantly, this bleeding is typically painless and can be sudden and profuse.
C. Uterine hypertonicity: Uterine hypertonicity refers to excessive, uncoordinated uterine contractions. Placenta previa is not generally associated with uterine hypertonicity; instead, it is more commonly linked with uterine relaxation and potential bleeding during contractions.
D. Persistent headache: A persistent headache is not a typical finding in placenta previa. However, it could be associated with conditions like preeclampsia, which might coexist with placenta previa but is a separate concern.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today