A pregnant woman's amniotic membranes rupture and a prolapsed umbilical cord is found. What intervention would be the first priority?
Placing the woman in the knee-chest position.
Starting oxygen by facemask.
Preparing the woman for a vaginal birth.
Covering the cord in sterile gauze soaked in saline.
The Correct Answer is A
In the case of a prolapsed umbilical cord, the first priority intervention is to relieve pressure on the cord. Placing the woman in the knee-chest position or Trendelenburg position with the hips elevated is the best way to achieve this. This position helps to reduce the compression of the cord and improve fetal oxygenation.
Option B is incorrect because while oxygen may be necessary, relieving pressure on the cord is the priority.
Option C is incorrect because a vaginal birth should not proceed with a prolapsed umbilical cord, as it can cause cord compression and fetal distress.
Option D is incorrect because covering the cord in sterile gauze soaked in saline is not a priority intervention and may not be effective in relieving pressure on the cord.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Based on the provided information, the probable diagnosis for the spontaneous abortion in this woman would be a threatened abortion, since the cervix is closed and there is no evidence of expulsion of fetal or placental tissue. A threatened abortion is defined as vaginal bleeding occurring before the 20th week of gestation, with a closed cervical os, and no expulsion of fetal or placental tissue.
The other types of spontaneous abortion are defined as follows:
B. Inevitable abortion: vaginal bleeding and cramping with an open cervical os, with or without expulsion of fetal or placental tissue
C. Missed abortion: fetal demise without expulsion of fetal tissue, and may be associated with a closed cervical os and absence of uterine contractions
D. Incomplete abortion: partial expulsion of fetal or placental tissue, with or without vaginal bleeding, and may be associated with an open cervical os and uterine contractions
Correct Answer is C
Explanation
In the case of a bioterrorism attack involving anthrax, the main priority for the nurse is to administer antibiotics within 48 hours of exposure using the Strategic National Stockpile. Anthrax is a serious bacterial infection that can be used as a bioterrorism weapon. Antibiotics, such as ciprofloxacin, doxycycline, and penicillin, can be used to prevent anthrax from developing in people who have been exposed.
There is currently no vaccine available for anthrax exposure. Also, symptom support alone is not enough in cases of anthrax exposure, as anthrax can progress rapidly and lead to serious complications. Placing everyone who was exposed in quarantine may not be necessary in all situations, and should be determined on a case-by-case basis depending on the extent and severity of the exposure.
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