A nurse is caring for a client who is in the active phase of labor. The nurse palpates the umbilical cord during a vaginal examination. Which of the following actions should the nurse take?
Decrease the rate of the IV infusion.
Place the client in a knee-chest position.
Instruct the client to push with the next contraction.
Replace the umbilical cord into the cervix
The Correct Answer is B
A. Decreasing IV infusion rate does not relieve umbilical cord prolapse.
B. Placing the client in a knee-chest position helps relieve pressure on the prolapsed umbilical cord, improving fetal oxygenation until delivery.
C. Instructing the client to push can worsen cord compression and is contraindicated.
D. The nurse should not attempt to replace the umbilical cord into the cervix; this is a sterile procedure typically performed by the provider.
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Related Questions
Correct Answer is D
Explanation
A. Monitoring cervical dilation is important but not the immediate priority.
B. Asking about the color of the amniotic fluid helps assess for meconium but is secondary.
C. Vaginal pH testing can help confirm rupture but is not the first action.
D. Determining the fetal heart rate is the priority to assess for signs of fetal distress immediately after rupture of membranes.
Correct Answer is D
Explanation
A. Fetal fibronectin testing is used to assess risk for preterm labor, not to confirm rupture of membranes.
B. Amniocentesis for fetal lung maturity is generally not needed at 37 weeks or later.
C. Urinalysis is for urinary tract issues, not for detecting amniotic fluid.
D. Nitrazine testing helps determine if vaginal fluid is amniotic fluid by assessing pH, aiding in diagnosing rupture of membranes.
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