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.

Answer and Explanation

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 .

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Correct Answer is B

Explanation

Nägele’s Rule is a method for estimating the expected date of delivery (EDD) or conﬁnement (EDC).

It involves adding seven days and one year, and subtracting three months, from the ﬁrst day of the last menstrual period (LMP)1.

Using this rule, if the ﬁrst day of the client’s last menstrual period was July 28th, then adding seven days would be August 4th.

Subtracting three months would be May 4th.

Adding one year would be May 4th of the following year.

Therefore, the nurse should document May 5th as the client’s expected delivery date.

Choice A is incorrect because April 21st is too early according to Nägele’s Rule calculation.

Choice C is incorrect because May 21st is too late according to Nägele’s Rule calculation.

Choice D is incorrect because April 4th is too early according to Nägele’s Rule calculation.

A. Restrict the newborn's ﬂuid intake. B. Keep the newborn in a side-lying position. C. Cover the newborn's bladder with a sterile, non-adherent dressing. D. Exert gentle pressure on the newborn's bladder with sterile gauze. E. Exert gentle pressure on the newborn's bladder with sterile gauze.

Correct Answer is C

Explanation

A nurse caring for a newborn who has exstrophy of the bladder should cover the newborn’s bladder with a sterile, non-adherent dressing prior to the beginning of surgical correction.

Choice A is incorrect because it is not necessary to restrict the newborn’s ﬂuid intake.

Choice B is incorrect because it is not necessary to keep the newborn in a side- lying position.

Choice D is incorrect because it is not appropriate to exert gentle pressure on

the newborn’s bladder with sterile gauze.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is using Nägele's Rule to calculate the expected delivery date of a client who reports that the first day of her last menstrual cycle was July 28th. Which of the following dates should the nurse document as the client's expected delivery date?

Correct Answer is B

Explanation

A nurse is caring for a newborn who has exstrophy of the bladder. Which of the following actions should the nurse take prior to the beginning of surgical correction?

Correct Answer is C

Explanation

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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?