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?

Insert a gloved hand into the vagina to relieve pressure on the cord.

Cover the cord with a sterile, moist saline dressing.

Place the client in knee-chest position.

Prepare the client for an immediate birth.

Answer and Explanation

The Correct Answer is C

A) Insert a gloved hand into the vagina to relieve pressure on the cord: While this action may be necessary in some cases, the priority in this situation is to relieve pressure on the umbilical cord to prevent cord compression. Placing the client in the knee-chest position is the most appropriate initial action to achieve this.
B) Cover the cord with a sterile, moist saline dressing: Applying a sterile, moist saline dressing is typically done after taking steps to relieve pressure on the umbilical cord. While it is important to keep the cord moist and protected, it is not the first action to take in this emergency situation.
C) Place the client in knee-chest position: Placing the client in the knee-chest position helps to relieve pressure on the umbilical cord by shifting the weight of the uterus off the cord. This position can help prevent cord compression and maintain fetal oxygenation, making it the priority action in this situation.
D) Prepare the client for an immediate birth: While preparing for a possible emergency birth may be necessary if the client is close to delivering, the immediate concern is relieving pressure on the umbilical cord to prevent fetal compromise. Placing the client in the knee-chest position should be the first action taken by the nurse to address the cord prolapse.

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Correct Answer is C

Explanation

A) Contractions are strong in intensity: Strong contractions are a normal and expected finding during the active phase of the first stage of labor. While it is important to monitor contraction intensity, strong contractions alone are not typically a cause for concern and would not warrant immediate reporting to the provider.
B) Client reports feeling contractions in the lower back: Back labor, where contractions are felt primarily in the lower back, is common during the active phase of labor. While this can be uncomfortable for the client, it is not usually an indication for immediate reporting to the provider.
C) Contractions occurring every 3 to 5 minutes: This finding indicates a pattern of contractions that is frequent and within the expected range for the active phase of labor. However, if the contractions become more frequent or the pattern changes significantly, it may be necessary to report this to the provider for further assessment.
D) Contractions lasting longer than 90 seconds: Prolonged contractions lasting longer than 90 seconds can be concerning as they may reduce uterine blood flow and oxygenation to the fetus. This finding should be reported to the provider for further evaluation and management.

A. Nausea B. Respiratory depression C. Drowsiness D. Facial flushing

Correct Answer is B

Explanation

A) Nausea: Nausea is a common side effect of magnesium sulfate therapy but is not necessarily indicative of magnesium sulfate toxicity. It is important to monitor for nausea, but it is not the most critical finding to indicate toxicity.
B) Respiratory depression: Respiratory depression is a severe sign of magnesium sulfate toxicity and should be reported to the provider immediately. Magnesium sulfate can depress the central nervous system, leading to respiratory depression, which is a potentially life-threatening complication.
C) Drowsiness: Drowsiness is a common side effect of magnesium sulfate therapy, especially at therapeutic levels. However, it is not necessarily indicative of magnesium sulfate toxicity. While drowsiness should be monitored, it is not as critical as respiratory depression in indicating toxicity.
D) Facial flushing: Facial flushing is a common side effect of magnesium sulfate therapy and is not typically associated with magnesium sulfate toxicity. While it can be uncomfortable for the patient, it is not a severe indication of toxicity compared to respiratory depression.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in the active phase of the first stage of labor. When monitoring the uterine contractions, which of the following findings should the nurse report to the provider?

Correct Answer is C

Explanation

A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity of magnesium sulfate therapy and report to the provider?

Correct Answer is B

Explanation

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