A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?
Cover the cord with a sterile, moist saline dressing
Place the client in knee-chest position
Insert a gloved hand into the vagina to relieve pressure on the cord
Prepare the client for an immediate birth
The Correct Answer is C
The correct answer is C. Insert a gloved hand into the vagina to relieve pressure on the cord.
A. Covering the cord with a sterile, moist saline dressing is a potential action, but relieving pressure on the cord takes precedence. This can be done by manually elevating the presenting part of the fetus off the cord.
B. Placing the client in a knee-chest position may be recommended after taking the immediate action of relieving pressure on the cord. Elevating the hips may help reduce cord compression.
C. Inserting a gloved hand into the vagina to relieve pressure on the cord is the priority action.
By manually lifting the presenting part off the cord, the nurse can help restore blood flow to the fetus and prevent umbilical cord compression.
D. Preparing the client for an immediate birth may be necessary, but the immediate action to relieve pressure on the cord should be performed first. The healthcare provider will determine the need for urgent delivery based on the clinical situation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The pattern of contractions is important in assessing labor, but the presence of regular contractions alone does not confirm true labor. It is the changes in the cervix that indicate progress in labor.
B. The station of the presenting part (the level at which the baby's head has descended into the pelvis) is also a factor in labor, but it is not the primary indicator of true labor. Changes in the cervix are more indicative.
C. Changes in the cervix are a key sign of true labor.
True labor involves cervical effacement (thinning) and dilation (opening). These changes in the cervix signify progress in the labor process.
D. Rupture of the membranes (water breaking) can be a sign of labor, but it doesn't confirm true labor on its own. It might occur before, during, or after labor has begun.
Correct Answer is A
Explanation
A. After notifying the provider, the nurse should massage the client’s fundus. This action helps to contract the uterus and reduce bleeding, which is crucial in managing hypovolemic shock due to postpartum hemorrhage.
B. Insert an indwelling urinary catheter: This action is important for monitoring urine output, which is a key indicator of renal perfusion and overall fluid status. However, it is not the immediate priority when managing hypovolemic shock due to postpartum hemorrhage.
C. Administer oxygen at 10 L/min: Providing oxygen is crucial to ensure adequate tissue oxygenation, especially in a shock state. While important, it comes after addressing the source of bleeding, which is the primary cause of the hypovolemic shock.
D. Elevate the client’s right hip: This action helps to prevent uterine displacement and improve venous return, which can be beneficial. However, it is not the first step in managing hypovolemic shock due to postpartum hemorrhage.
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