A patient’s umbilical cord prolapses during labor induction with oxytocin infusion.
Which action by the nurse takes priority?
Stop oxytocin infusion immediately
Place patient in knee-chest position
Apply pressure to presenting part with hand
Administer oxygen via non-rebreather mask
The Correct Answer is C
The correct answer is choice C. Apply pressure to presenting part with hand.
This is because cord prolapse is an emergency situation that requires immediate delivery to save the fetus. Applying pressure to the presenting part with hand can help relieve the compression of the cord and maintain fetal oxygenation until delivery.
Choice A is wrong because stopping oxytocin infusion will not prevent cord compression or fetal hypoxia. Oxytocin may be stopped after applying pressure to the presenting part and notifying the physician.
Choice B is wrong because placing the patient in knee-chest position may not be effective in relieving cord compression.
It may also be uncomfortable and difficult for the patient to maintain. A better position would be Trendelenburg or modified Sims.
Choice D is wrong because administering oxygen via non-rebreather mask is not a priority action. Oxygen may be given after applying pressure to the presenting part and notifying the physician, but it will not improve fetal oxygenation if the cord is compressed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. A patient who is 34 weeks pregnant with a breech presentation and ruptured membranes.This is because breech presentation and ruptured membranes are both risk factors for umbilical cord prolapse, which is where the umbilical cord descends through the cervix and is alongside or below the presenting part of the fetus.This can cause fetal hypoxia and distress.
Choice A is wrong because a cephalic presentation and intact membranes are not risk factors for umbilical cord prolapse.
Choice B is wrong because although twins and ruptured membranes are risk factors for umbilical cord prolapse, the risk is lower than in choice D. Choice C is wrong because although a transverse lie is a risk factor for umbilical cord prolapse, the risk is lower than in choice D if the membranes are intact.
Correct Answer is ["A","B"]
Explanation
The correct answer is choice A and B. The nurse should place the patient in knee-chest or Trendelenburg position to relieve the pressure of the fetal presenting part on the prolapsed cord and improve fetal oxygenation.These positions also allow gravity to help keep the cord in the uterus and prevent further descent.
Choice C is wrong because supine position can worsen cord compression and compromise fetal blood flow.Choice D is wrong because lithotomy position can also increase cord descent and reduce fetal perfusion.Choice E is wrong because Sims position can cause cord prolapse if the membranes are intact or rupture spontaneously.
Normal ranges for fetal heart rate are 110 to 160 beats per minute.Cord prolapse can cause fetal bradycardia with decelerations during contractions due to cord compression.
This is a sign of fetal distress and requires immediate intervention.
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