A nurse is caring for a client who is in labor.

Exhibits

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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Privately interviewing the client is the first step in assessing the possibility of elder abuse and gathering detailed information.

B. Notifying risk management is necessary after abuse is confirmed or suspected, but it is not the first step.

C. Informing the transferring agency is not appropriate until further investigation.

D. Contacting the family may not be appropriate if they are suspected of abuse.

A. Position the client's knees slightly higher than the hips when up in a chair. B. Keep an abduction pillow between the client's legs. C. Raise the head of the client's bed to a high-Fowler's position. D. Elevate the client's affected leg on a pillow when in bed.

Correct Answer is B

Explanation

A. Positioning the knees higher than the hips could increase the risk of hip dislocation.

B. Keeping an abduction pillow between the legs helps maintain the hip in the correct position and prevents dislocation.

C. Raising the head of the bed to a high-Fowler’s position may strain the hip and is not recommended for dislocation prevention.

D. Elevating the affected leg on a pillow may cause internal rotation and increase the risk of dislocation.

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A nurse is caring for a client who is in labor. Exhibits Select the 5 actions the nurse should take.

Nursing Test Bank

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A nurse is caring for a client who is in labor.

Exhibits

Select the 5 actions the nurse should take.