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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Facial petechiae are small, pinpoint, red or purple spots on the skin that result from minor bleeding from broken capillary blood vessels. They can occur as a result of a nuchal cord, which is when the umbilical cord becomes wrapped around the fetus’s neck. This can cause pressure and minor injuries, leading to the appearance of petechiae.
Choice B rationale
Periauricular papillomas are not typically associated with a nuchal cord. They are small, benign skin growths that occur near the ear. They are not a common finding in newborns and are not related to the conditions of birth.
Choice C rationale
Erythema toxicum is a common rash seen in newborns, characterized by tiny bumps surrounded by an area of red skin. It is not specifically associated with a nuchal cord.
Choice D rationale
Telangiectatic nevi, also known as “stork bites,” are common birthmarks seen in newborns, characterized by patches of pink or red skin. They are not specifically associated with a nuchal cord.
Correct Answer is B
Explanation
Choice A rationale
Progressive sacral discomfort during contractions is a normal part of labor and does not necessarily require reassessment.
Choice B rationale
An urge to have a bowel movement during contractions could indicate that the baby’s head is descending into the birth canal. This could signal that the labor is progressing more quickly than expected, and the nurse should reassess the client.
Choice C rationale
Intense contractions lasting 45 to 60 seconds are a normal part of active labor and do not necessarily require reassessment.
Choice D rationale
A sense of excitement and warm, flushed skin are normal emotional and physiological responses to labor and do not necessarily require reassessment.
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