A nurse is caring for a client who reports spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and notices that the umbilical cord is protruding.
After calling for assistance and notifying the provider, which of the following actions should the nurse take next?
Cover the umbilical cord with a sterile saline saturated towel.
Perform a vaginal examination by applying upward pressure on the presenting part.
Administer oxygen via non-rebreather mask at 8 L/min.
Initiate an infusion of IV fluids for the client.
The Correct Answer is B
If a prolapsed cord is identified, the nurse should perform a vaginal examination and ensure the presenting part is pushed upwards to relieve pressure on the cord.
Choice A) is not correct because while it is important to cover the cord with a sterile saline saturated towel if it has prolapsed externally 1, it is not the next action after calling for assistance and notifying the provider.
Choice C) is not correct because administering oxygen via non-rebreather mask at 8 L/min is not mentioned as an immediate intervention for a prolapsed cord .
Choice D) is not correct because initiating an infusion of IV fluids for the client is not mentioned as an immediate intervention for a prolapsed cord .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A nurse conducting a class for a group of clients about birth control should include information about having an annual examination to assess their diaphragm.
A diaphragm should be replaced at least every 2 years and it’s important to
bring it to an annual checkup so the healthcare provider can check the fit.
Choice A is incorrect because spermicide should be used immediately before sexual intercourse, not 3 hours prior.
Choice B is incorrect because fertility can return immediately after IUD removal.
Choice C is incorrect because emergency contraception is intended for backup contraception only and not as a primary method of birth control
Correct Answer is D
Explanation
A nurse caring for a client who is receiving prenatal care and is at her 24-week appointment should plan to conduct a one-hour glucose tolerance test.
This test is done to screen for gestational diabetes that can develop during pregnancy.
Choice A, Group B strep culture, is not an answer because it is a test usually done between 35-37 weeks of pregnancy to check for the presence of Group B streptococcus bacteria.
Choice B, Rubella titer, is not an answer because it is a blood test usually done early in pregnancy to check for immunity to rubella.
Choice C, Blood type and Rh, is not an answer because it is a blood test usually done early in pregnancy to determine the mother’s blood type and Rh factor.
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