A nurse is caring for a client who is in labor.
Select the 5 actions the nurse should take.
Exert upward pressure on the presenting part.
Place the client in a Trendelenburg position.
Administer oxygen at 10 L/min via nonrebreather face mask.
Attempt to push the umbilical cord back into the cervix.
Have the charge nurse notify the provider.
Increase the flow rate of the maintenance IV fluid.
Correct Answer : A,B,C,E,F
A. Exert upward pressure on the presenting part. If there are signs of cord prolapse or pressure on the umbilical cord, exerting upward pressure on the presenting part can relieve compression. This action helps maintain blood flow and oxygen supply to the fetus.
B. Place the client in a Trendelenburg position. Positioning the client with the pelvis elevated higher than the head can reduce pressure on the umbilical cord if prolapse is suspected or confirmed. This promotes fetal circulation and decreases the risk of hypoxia.
C. Administer oxygen at 10 L/min via nonrebreather face mask. Administering high-flow oxygen increases maternal oxygenation, which in turn improves oxygen delivery to the fetus. This is a priority intervention to ensure fetal well-being during labor.
D. Attempt to push the umbilical cord back into the cervix. This is incorrect because pushing the cord back into the cervix is contraindicated due to the risk of damaging the cord or introducing infection. Other measures, such as repositioning and elevating the presenting part, should be prioritized instead.
E. Have the charge nurse notify the provider. Timely communication with the provider is critical when complications arise during labor, such as suspected umbilical cord prolapse. The provider may need to intervene urgently, possibly requiring an emergency cesarean section.
F. Increase the flow rate of the maintenance IV fluid. Increasing the IV fluid rate helps improve maternal circulation and blood flow to the uterus and placenta, ensuring the fetus receives adequate oxygen and nutrients. This is a supportive measure during labor when complications arise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Milkshake made with whole milk is high in saturated fats and sugar, making it less healthy.
B. Cheesecake is a high-calorie, high-fat dessert and not a healthy snack option.
C. Air-popped popcorn is a whole grain, low-calorie, and fiber-rich snack, making it a healthy choice.
D. Baked potato chips are a better option than fried chips but still contain added salt and fat.
Correct Answer is ["B","C","E","F","G"]
Explanation
A. Perform a vaginal examination every 12 hr. Routine vaginal examinations are not indicated at this stage of care, as there are no signs of labor or uterine contractions. Vaginal exams should only be performed if there are indications of preterm labor or changes in maternal symptoms.
B. Obtain a 24-hr urine specimen. Collecting a 24-hour urine specimen allows for accurate measurement of total protein excretion, which is critical for confirming the severity of preeclampsia. This diagnostic tool helps guide further management decisions.
C. Administer betamethasone. Betamethasone is given to promote fetal lung maturity in the event of a preterm delivery, which is a significant risk at 31 weeks of gestation in the presence of severe preeclampsia. It reduces neonatal morbidity and mortality.
D. Monitor intake and output hourly. While monitoring fluid status is essential, hourly monitoring is not typically required unless there are signs of worsening renal function, oliguria, or fluid imbalance. Regular but less frequent monitoring is sufficient for this client.
E. Give antihypertensive medication. The client's blood pressure readings of 162/112 mm Hg and 166/110 mm Hg require prompt antihypertensive treatment to reduce the risk of complications such as stroke, placental abruption, or eclampsia.
F. Provide a low-stimulation environment. A quiet, low-stimulation environment helps reduce the risk of seizures, which is a concern for clients with severe preeclampsia. This intervention supports neurological stability.
G. Maintain bed rest. Bed rest minimizes physical exertion, helping to lower blood pressure and improve placental perfusion, which is critical for fetal well-being in a client with severe preeclampsia.
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