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 D

Explanation

Choice A rationale
While breast tenderness can be a side effect of oral contraceptives, it is not typically a sign of a serious problem. It may occur as the body adjusts to the hormones in the medication.
However, if the tenderness is severe or persists, the client should consult their healthcare provider.
Choice B rationale
Pain during intercourse is not typically associated with the use of oral contraceptives. If a client experiences this symptom, it may be due to other causes such as infection, inflammation, or certain medical conditions. It’s important to seek medical advice if this symptom occurs.
Choice C rationale
Unusual vaginal discharge can be a side effect of oral contraceptives, but it is not typically a sign of a serious problem. Changes in the color, consistency, or smell of vaginal discharge could indicate an infection or other medical condition and should be evaluated by a healthcare provider.
Choice D rationale

Severe abdominal pain is a symptom that the client should report to the provider immediately. This could be a sign of a serious problem such as a blood clot or liver disease. It’s important to seek immediate medical attention if this symptom occurs.

A. Patient who has a urinary output of 300 ml in 8 hours B. Patient who reports lochia rubra requiring changing perineal pads every 3 hours C. Patient who is receiving magnesium sulfate and has absent deep tendon reflexes D. Patient who reports abdominal cramping during breastfeeding

Correct Answer is C

Explanation

Choice A rationale
A urinary output of 300 ml in 8 hours is within the normal range for a postpartum patient. The average urinary output is about 30 ml/hour.
Choice B rationale
Lochia rubra is a normal finding in the immediate postpartum period. It is the initial vaginal discharge after childbirth, which is red because it contains a large amount of blood. Changing perineal pads every 3 hours is considered normal.
Choice C rationale

A patient who is receiving magnesium sulfate and has absent deep tendon reflexes is experiencing magnesium toxicity. This is a serious condition that can lead to respiratory depression and cardiac arrest. The healthcare provider should be notified immediately.
Choice D rationale
Abdominal cramping during breastfeeding is a normal finding. During breastfeeding, the hormone oxytocin is released which can cause uterine contractions and lead to cramping.

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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 caring for a client who is taking an oral contraceptive. What findings should the client report to the provider immediately?

Correct Answer is D

Explanation

A nurse on the postpartum unit is caring for four patients. For which of the following patients should the nurse notify the provider?

Correct Answer is C

Explanation

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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 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?

A nurse is providing teaching about the expected effects of magnesium sulfate to a client who is at 28 weeks of gestation and has preeclampsia. Which of the following responses by the nurse is appropriate?