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 A

Explanation

Choice A rationale
Facial asymmetry can occur as a result of a forceps-assisted birth. The pressure from the forceps can cause temporary changes in the shape of the baby’s face.
Choice B rationale
Caput succedaneum, a swelling of the scalp in a newborn, is not typically caused by forceps. It is more commonly associated with vacuum extraction.
Choice C rationale
Cephalohematoma, a bleeding underneath one of the cranial bones, is not typically caused by forceps. It is more commonly associated with vacuum extraction.
Choice D rationale

Subgaleal hemorrhage, bleeding into the space between the skull periosteum and the scalp galea aponeurosis, is not typically caused by forceps. It is more commonly associated with vacuum extraction.

A. Transient occipital cyanosis B. Single palmar creases C. Subconjunctival hemorrhage D. Dystocia . user Rewrite the Questions below.

Correct Answer is B

Explanation

Choice A rationale
Transient occipital cyanosis is not a clinical finding that should be reported to the provider. It is a normal finding in newborns due to immature circulation and should resolve on its own.
Choice B rationale
Single palmar creases, also known as simian lines, can be a sign of certain genetic conditions, such as Down syndrome. Therefore, this finding should be reported to the provider.
Choice C rationale
Subconjunctival hemorrhage, or a red spot in the white of the eye, is a common and harmless condition in newborns. It does not require treatment and will disappear as the blood is absorbed.
Choice D rationale

Dystocia, or difficult labor, is not a clinical finding in a newborn. It refers to a situation during childbirth where there is slow or difficult labor or delivery.

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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 is assessing a newborn who was born via a forceps-assisted birth. Which of the following findings should the nurse identify as an injury caused by the forceps?

Correct Answer is A

Explanation

A nurse is assessing a full-term newborn upon admission to the nursery. What clinical findings should the nurse report to the provider?

Correct Answer is B

Explanation

A nurse is caring for a client in labor who is experiencing abruptio placentae. What findings should the nurse expect?

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