A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?
Insert a gloved hand into the vagina to relieve pressure on the cord.
Cover the cord with a sterile, moist saline dressing.
Place the client in knee-chest position.
Prepare the client for an immediate birth.
The Correct Answer is A
Choice A reason: This action is the first and most important intervention that the nurse should perform, as it can prevent or reduce the compression of the umbilical cord, which can cause fetal hypoxia, bradycardia, or death. The nurse should insert a gloved hand into the vagina and gently push the presenting part away from the cord, and maintain this position until the delivery.
Choice B reason: This action is not the first intervention that the nurse should perform, as it does not address the cause of the cord prolapse, which is the displacement of the cord below the presenting part. However, this action is helpful to prevent the drying and infection of the cord, and should be done after the first intervention.
Choice C reason: This action is not the first intervention that the nurse should perform, as it may not be effective or feasible depending on the stage of labor and the client's condition. However, this action is beneficial to reduce the pressure of the presenting part on the cord, and should be done after the first intervention.
Choice D reason: This action is not the first intervention that the nurse should perform, as it does not provide immediate relief or protection to the fetus. However, this action is necessary to expedite the delivery and prevent further complications, and should be done after the first intervention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Administering oxygen via nasal cannula is not a necessary intervention for the client, unless she has signs of hypoxia, such as dyspnea, tachypnea, or cyanosis. Oxygen administration is not routinely indicated for clients with inevitable abortion.
Choice B reason: Offering option to view products of conception is an appropriate intervention for the client, because it can help her cope with the loss of pregnancy and facilitate the grieving process. The nurse should respect the client's decision and provide emotional support.
Choice C reason: Instructing the client to increase potassium-rich foods in the diet is not a relevant intervention for the client, unless she has signs of hypokalemia, such as muscle weakness, cramps, or arrhythmias. Potassium intake is not related to the cause or prevention of inevitable abortion.
Choice D reason: Maintaining the client in a Trendelenburg position is not a recommended intervention for the client, because it can increase the risk of aspiration, respiratory compromise, and venous congestion. Trendelenburg position is not effective in preventing or treating inevitable abortion.
Correct Answer is C
Explanation
Choice A reason: This statement is incorrect, as surfactant is not an antibiotic and does not treat infections. Surfactant is a substance that is naturally produced by the lungs to reduce the surface tension and prevent the alveoli from collapsing. Premature infants may have insufficient surfactant, which can cause RDS.
Choice B reason: This statement is partially true, as surfactant can help reduce episodes of periodic apnea, which is a condition where the newborn stops breathing for more than 20 seconds. However, this is not the main purpose of surfactant therapy, and other interventions, such as oxygen, ventilation, and caffeine, may be needed to treat apnea.
Choice C reason: This statement is correct, as surfactant improves the ability of the baby's lungs to exchange oxygen and carbon dioxide, which are essential for life. Surfactant therapy can improve the lung function, reduce the need for mechanical ventilation, and prevent complications, such as bronchopulmonary dysplasia and pulmonary hemorrhage.
Choice D reason: This statement is false, as surfactant does not affect the level of sedation in the newborn. Surfactant is administered through an endotracheal tube, which may require sedation to reduce discomfort and agitation. The nurse should monitor the newborn's vital signs, oxygen saturation, and pain level during and after the procedure.
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