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 NOT perform?

Take pressure off of the presenting part of the fetal head.

Prepare the client for an immediate cesarean birth.

Place the client in a knee-chest position.

Attempt to gently put the cord back inside.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Taking pressure off of the presenting part of the fetal head can help improve blood flow and oxygen supply to the fetus, potentially preventing hypoxia.

Choice B rationale

Preparing the client for an immediate cesarean birth is a necessary step in cases of umbilical cord prolapse to quickly deliver the baby and reduce the risk of fetal distress.

Choice C rationale

Placing the client in a knee-chest position helps to alleviate pressure on the umbilical cord, increasing blood flow and oxygen supply to the fetus.

Choice D rationale

Attempting to gently put the cord back inside is not recommended as it can cause more harm and increase the risk of cord compression and infection.

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Correct Answer is A

Explanation

Choice A rationale

Squatting and pelvic lunges are natural positions and exercises that can help with labor progression, but they are not medically recognized methods for inducing labor. These activities may help move the baby into a better position but do not stimulate contractions effectively for labor induction.

Choice B rationale

Amniotomy involves the intentional rupture of the amniotic sac to release amniotic fluid. This procedure can stimulate uterine contractions and is a common method used to induce labor when conditions are appropriate.

Choice C rationale

Oxytocin is a hormone that stimulates uterine contractions. It is commonly administered intravenously to induce or augment labor, making it an effective and widely used method for labor induction.

Choice D rationale

Dinoprostone is a prostaglandin used to ripen the cervix and induce labor. It is applied either as a vaginal insert or gel and helps soften and dilate the cervix, preparing it for labor.

A. Ergonovine maleate. B. Epoetin. C. Adrenaline. D. Ephedrine.

Correct Answer is D

Explanation

Choice A rationale

Ergonovine maleate is used to treat postpartum hemorrhage by causing uterine contractions. It is not used to treat hypotension caused by epidural anesthesia.

Choice B rationale

Epoetin is a medication used to treat anemia by stimulating the production of red blood cells. It is not used to treat hypotension caused by epidural anesthesia.

Choice C rationale

Adrenaline (epinephrine) is used in emergency situations to treat severe allergic reactions, cardiac arrest, and severe asthma attacks. It is not the first-line treatment for hypotension caused by epidural anesthesia.

Choice D rationale

Ephedrine is a medication used to treat hypotension caused by epidural anesthesia. It increases blood pressure by stimulating the release of norepinephrine and improving cardiac output.

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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 NOT perform?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

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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 NOT perform?