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

Answer and Explanation

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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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.

A. Abdominal assessment B. Low back pain C. Uterine contractions D. Abdominal cramping E. Fundal height F. Fetal heart rate

Correct Answer is ["A","B","D"]

Explanation

A. Abdominal assessment – The abdomen is tender to palpation, which is an abnormal finding and can indicate uterine activity or irritation associated with preterm labor or other complications.
B. Low back pain – This is a common early sign of preterm labor, especially when combined with uterine cramping and cervical changes.
C. Uterine contractions – Although the client has cramping, there is no specific documentation of palpable or monitor-confirmed contractions, so this cannot be definitively selected based on available data.
D. Abdominal cramping – This is concerning in a pregnant client at 30 weeks, especially in combination with cervical dilation, vaginal bleeding, and back pain.
E. Fundal height – At 30 weeks, a fundal height of 28 cm is within the normal range (should match gestational age ±2 cm). This is not abnormal.
F. Fetal heart rate – The scenario notes positive fetal movement but does not mention an abnormal FHR. Without abnormal FHR data, this cannot be selected.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 37 weeks of gestation and reports a slow trickle of vaginal fluid for the past 12 hr. Which of the following diagnostic tests should the nurse anticipate?

Correct Answer is D

Explanation

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Correct Answer is ["A","B","D"]

Explanation

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