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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Erythroblastosis fetalis is the correct answer, as it is a hemolytic disease of the newborn that occurs when the mother is Rh-negative and the newborn is Rh-positive, and the maternal antibodies cross the placenta and destroy the newborn's red blood cells, causing anemia, jaundice, and edema. Rh0 (D) immunoglobulin is an injection that prevents the formation of Rh-positive antibodies in the mother, and reduces the risk of erythroblastosis fetalis in the current or subsequent pregnancies.
Choice B reason: Hypobilirubinemia is not the correct answer, as it is a low level of bilirubin in the blood that can cause pale skin, poor feeding, or lethargy. Hypobilirubinemia is not related to the Rh factor or the Rh0 (D) immunoglobulin injection, and it is not a common or serious complication in the newborn.
Choice C reason: Biliary atresia is not the correct answer, as it is a congenital defect of the bile ducts that prevents the flow of bile from the liver to the intestine, causing jaundice, dark urine, and clay-colored stools. Biliary atresia is not related to the Rh factor or the Rh0 (D) immunoglobulin injection, and it is not a preventable complication in the newborn.
Choice D reason: Transient clotting difficulties is not the correct answer, as it is a bleeding disorder that occurs due to the deficiency of vitamin K, which is essential for the synthesis of clotting factors. Transient clotting difficulties is not related to the Rh factor or the Rh0 (D) immunoglobulin injection, and it is preventable by administering vitamin K to the newborn.
Correct Answer is A
Explanation
Choice A reason: The mother applying lotion to the newborn's skin requires intervention by the nurse, because it can interfere with the effectiveness of phototherapy and increase the risk of thermal injury. The nurse should instruct the mother to avoid using any lotions, creams, or oils on the newborn's skin during phototherapy.
Choice B reason: The newborn's stools increasing in number does not require intervention by the nurse, because it is a normal and expected outcome of phototherapy. Phototherapy can increase the breakdown and excretion of bilirubin, which can result in more frequent and loose stools.
Choice C reason: A pink rash appearing on the newborn's trunk does not require intervention by the nurse, because it is a common and harmless side effect of phototherapy. The rash usually disappears within a few days after phototherapy is discontinued.
Choice D reason: The newborn's eyes being covered with a mask does not require intervention by the nurse, because it is a standard and essential precaution for phototherapy. The mask protects the newborn's eyes from the harmful effects of the light, such as corneal damage or retinal injury.
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