A nurse is caring for a client who is in the second stage of labor.
The nurse observes the umbilical cord protruding from the vagina.
Which of the following actions should the nurse perform first?
No action is needed, this is an expected finding in the second stage of labor.
Insert a gloved hand into the vagina to elevate the presenting part.
Encourage the client to start pushing.
Place the client in a lateral position.
The Correct Answer is B
Choice A rationale
Protrusion of the umbilical cord from the vagina is a medical emergency known as umbilical cord prolapse. It is not an expected finding and requires immediate intervention to prevent fetal hypoxia.
Choice B rationale
Inserting a gloved hand into the vagina to elevate the presenting part is the correct immediate action. This helps relieve pressure on the umbilical cord and maintain blood flow to the fetus until more definitive interventions can be performed.
Choice C rationale
Encouraging the client to push would increase pressure on the umbilical cord and can lead to reduced oxygen supply to the fetus, worsening the situation.
Choice D rationale
Placing the client in a lateral position might help to some extent, but it is not the primary or most effective intervention for umbilical cord prolapse. Immediate manual elevation of the presenting part is required.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
The condition of imminent delivery is correct because the client, gravida 5 para 4 at 39 weeks gestation, is experiencing strong contractions and rectal pressure indicative of advanced labor stages. The physical examination supports active labor, with a firm, palpable uterus, and fetal heart rate present. The urgency of notifying the healthcare provider and encouraging bearing down aligns with labor management in advanced stages. Cervical dilation is essential to assess labor progression, and fetal heart rate monitoring ensures fetal well-being during delivery.
Actions and Parameters Rationale:
- Notifying the healthcare provider immediately ensures timely medical intervention, crucial for safe delivery and management of any complications.
- Encouraging the client to bear down with contractions aids the birthing process by utilizing the client’s natural efforts in the expulsion phase of labor.
- Monitoring cervical dilation provides insight into how far along the client is in labor, helping to anticipate the time of delivery.
- Continuous monitoring of fetal heart rate ensures the baby's well-being, detecting any distress during labor.
Incorrect Conditions:
- Preterm labor (A): The client is at 39 weeks gestation, so the labor is not preterm.
- Placental abruption (B): There are no signs of placental abruption, such as vaginal bleeding, uterine tenderness, or abnormal fetal heart rate patterns.
- Prolapsed umbilical cord (C): There is no indication of a prolapsed cord, such as sudden fetal distress or visible/palpable cord.
Correct Answer is ["500"]
Explanation
Step 1 is calculate the total volume to be infused: 250 mL
Step 2 is determine the time in hours: 30 minutes ÷ 60 minutes/hour = 0.5 hours.
Step 3 is calculate the rate in mL/hour: 250 mL ÷ 0.5 hours = 500 mL/hour.
The nurse will program the IV pump for 500 mL/hour.
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