A nurse is caring for a client who is in labor.The nurse notes that the umbilical cord is protruding from the client’s vagina. Which of the following actions should the nurse take first?

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

Exert upward pressure on the presenting part

Answer and Explanation

The Correct Answer is D

The correct answer is choice d. Exert upward pressure on the presenting part.

Choice A rationale:

Administering a tocolytic medication can help reduce uterine contractions, but it is not the immediate priority in this emergency situation. The primary goal is to relieve pressure on the umbilical cord to restore blood flow to the fetus.

Choice B rationale:

Wrapping the cord in a sterile towel moistened with warm sterile normal saline is important to prevent the cord from drying out and to maintain its temperature. However, this action does not address the immediate need to relieve pressure on the cord.

Choice C rationale:

Applying oxygen via facemask to the client can help improve maternal oxygenation, which indirectly benefits the fetus. However, it does not directly address the immediate issue of relieving pressure on the umbilical cord.

Choice D rationale:

Exerting upward pressure on the presenting part is the most critical action to take first. This maneuver helps to relieve pressure on the umbilical cord, thereby restoring blood flow and oxygen to the fetus, which is essential in this emergency situation.

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Correct Answer is B

Explanation

Choice A rationale
Asking why the adolescent is requesting birth control may come across as judgmental and could discourage open communication.
Choice B rationale
Understanding what the adolescent knows about contraception can help guide the discussion and ensure that she is making an informed decision.
Choice C rationale

Whether or not the partner loves the adolescent is not directly relevant to the decision to use birth control. The focus should be on the adolescent’s reproductive health and autonomy.
Choice D rationale
While it’s important to discuss coercion in sexual relationships, this question could be seen as intrusive or presumptive. It’s more appropriate to provide information about healthy relationships and consent.

A. Yellow exudate will form at the surgical site in 24 hours B. The Plastibell will be removed 4 hours after the procedure C. Make sure the newborn’s diaper is snug D. Notify the provider if the end of your baby’s penis appears dark red

Correct Answer is A

Explanation

This is the correct answer. After a Plastibell circumcision, a yellow exudate, which is part of the normal healing process, will form at the surgical site within 24 hours.
Choice B rationale
The Plastibell device is not removed 4 hours after the procedure. It falls off naturally after seven to 10 days.
Choice C rationale
Making sure the newborn’s diaper is snug is not a specific instruction related to the Plastibell circumcision technique.
Choice D rationale
Notifying the provider if the end of the baby’s penis appears dark red is not a specific instruction related to the Plastibell circumcision technique.

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A nurse is caring for a client who is in labor.The nurse notes that the umbilical cord is protruding from the client’s vagina. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a clinic is caring for an adolescent patient who requests a prescription for birth control. Which of the following Questions should the nurse ask?

Correct Answer is B

Explanation

A nurse is providing teaching to the parents of a newborn about the Plastibell circumcision technique. Which of the following information should the nurse include?

Correct Answer is A

Explanation

A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. What information should the nurse manager include in the teaching?

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A nurse is caring for a client who is in labor.The nurse notes that the umbilical cord is protruding from the client’s vagina. Which of the following actions should the nurse take first?

A nurse is assessing a newborn of a client who reported methadone use during pregnancy. What manifestations should the nurse expect the newborn to exhibit?