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
A blood pressure of 88/40 mm Hg is significantly lower than the normal range, which could indicate hemorrhage. Hypotension is a common sign of significant blood loss.
Choice B rationale
Moderate rubra lochia is normal within the first few days postpartum and does not necessarily indicate hemorrhage.
Choice C rationale
A heart rate of 90/min is within the normal range and does not indicate hemorrhage.
Choice D rationale
A urinary output of 40 mL/hr is within the normal range and does not indicate hemorrhage.
Correct Answer is A
Explanation
Choice A rationale
Puncturing the lateral side of the heel is the correct procedure when performing a heel stick on a newborn. This area is less likely to come into contact with hard surfaces that could cause injury to the puncture site.
Choice B rationale
A 21-gauge needle is too large for a heel stick procedure on a newborn. A smaller gauge needle or a lancet is typically used to ensure the puncture is as small and painless as possible.
Choice C rationale
Applying an alcohol pad to the site after the procedure is not recommended. Alcohol can cause skin irritation and dryness. Instead, a sterile gauze or bandage is usually applied to stop any bleeding from the puncture site.
Choice D rationale
Placing a cold cloth at the site for 15 minutes before the procedure is not recommended. Cold can cause vasoconstriction, which would make it more difficult to obtain a blood sample.
Instead, warming the heel prior to the stick can help to increase blood flow to the area.
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