During the initial assessment of a newborn, the nurse observes that the umbilical cord contains two arteries and one vein. Which nursing action is most appropriate?
Notify the healthcare provider, as this finding may be associated with congenital anomalies.
Document the finding as normal and continue with routine newborn care.
Apply warm compresses to the cord to promote circulation.
Document the finding as abnormal and continue with routine newborn care.
The Correct Answer is B
A. Notify the healthcare provider, as this finding may be associated with congenital anomalies: Two arteries and one vein represent the normal anatomy of the umbilical cord. Notification is unnecessary unless only one artery (a single umbilical artery) is present, which could indicate possible congenital anomalies.
B. Document the finding as normal and continue with routine newborn care: The normal umbilical cord structure consists of two arteries that carry deoxygenated blood from the fetus and one vein that returns oxygenated blood to the fetus. This finding confirms a normal cord and requires no additional interventions beyond standard care.
C. Apply warm compresses to the cord to promote circulation: The umbilical cord no longer functions in circulation after birth. Applying warm compresses would serve no purpose and could introduce unnecessary risk of infection or injury to the cord stump.
D. Document the finding as abnormal and continue with routine newborn care: Labeling a normal finding as abnormal could lead to confusion in medical records and unnecessary evaluations. Proper documentation should accurately reflect the expected normal anatomy of two arteries and one vein.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The false pelvis forms the bony canal through which the fetus passes during birth: The bony birth canal is formed by the true pelvis, not the false pelvis. The true pelvis encloses the pelvic inlet, midpelvis, and outlet—structures essential for fetal passage during labor.
B. The true pelvis supports the intestines and helps direct the fetus into the pelvic inlet: The true pelvis does not primarily support the intestines; instead, it provides the pathway through which the fetus must navigate during delivery. It forms the lower, curved portion of the pelvis involved in childbirth.
C. The false pelvis is located above the pelvic brim and is not directly involved in childbirth: The false pelvis lies superior to the pelvic brim and mainly supports abdominal organs such as the intestines. It plays a minimal role in labor mechanics since it does not contribute to the bony canal through which the fetus passes.
D. The true pelvis lies above the pelvic brim and provides structural support to abdominal organs: The true pelvis is actually located below the pelvic brim and encloses the pelvic cavity, which forms the birth canal. It is the false pelvis that supports the abdominal organs.
Correct Answer is ["On her left side"]
Explanation
Sleeping on the left side enhances venous return and optimizes uteroplacental blood flow by preventing compression of the inferior vena cava and aorta by the gravid uterus. This position promotes better oxygen and nutrient delivery to the fetus while reducing maternal hypotension, dizziness, and edema. Supine or right-side sleeping can impair circulation, leading to decreased cardiac output and fetal perfusion, especially in later pregnancy.
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