The nurse assesses a client in labor due to a noted prolonged fetal heart rate deceleration (HR 118 bpm) on the monitor. Upon entering the room, the client reports "a feeling of something weird between her legs," and the nurse notes an umbilical cord prolapse upon assessment. The nurse immediately alerts the team and educates the client about the complication and nursing interventions.
What is the priority nursing intervention when umbilical cord prolapse is noted?
Placing a rolled towel under the client's knees.
Immediately notifying the client's obstetric health care provider.
Administering oxygen to the client via a non-rebreather mask.
Positioning the client to relieve pressure on the prolapsed cord, such as the Trendelenburg or knee-chest position.
Preparing the client for an immediate vacuum-assisted delivery.
The Correct Answer is D
Choice A rationale
Placing a rolled towel under the client's knees might slightly tilt the pelvis but is insufficient to effectively relieve the pressure of the presenting fetal part on the prolapsed umbilical cord. The primary goal in a cord prolapse is to prevent umbilical artery compression, which quickly leads to fetal hypoxia and bradycardia due to compromised blood flow, and a rolled towel under the knees doesn't achieve the necessary change in maternal position to shift the fetus off the cord.
Choice B rationale
While immediately notifying the obstetric health care provider (HCP) is a critical step in managing cord prolapse, it is not the absolute priority over direct physical intervention to protect the fetus. The scientific rationale for prioritizing pressure relief is the immediate threat of profound fetal hypoxemia and acidemia from cord compression, which can cause irreversible brain damage or death within minutes, necessitating an immediate hands-on maneuver.
Choice C rationale
Administering high-flow oxygen via a non-rebreather mask (10-12 L/min) is a standard intervention for fetal distress, aiming to increase the maternal partial pressure of oxygen (P_O_2) and subsequently enhance oxygen transfer across the placenta to the fetus. However, its effectiveness is secondary to relieving the direct mechanical compression of the umbilical cord, which is the immediate cause of the deceleration and hypoxia.
Choice D rationale
Positioning the client into a position like Trendelenburg (head down, feet up) or knee-chest (hands and knees, chest on the bed) uses gravity to displace the fetus upward and away from the cervix, thereby relieving the pressure on the prolapsed umbilical cord. This action immediately restores umbilical blood flow, which is the critical first step to reversing fetal bradycardia and hypoxia caused by cord compression.
Choice E rationale
Preparing the client for an immediate delivery, often via emergency Cesarean section (C-section), is the ultimate treatment for a non-reassuring fetal status secondary to cord prolapse, but it requires preparatory steps and time. Positioning for pressure relief (Choice D) and manual elevation of the presenting part (if necessary) are the immediate, life-saving measures performed before or concurrent with preparation for rapid delivery.
Choice F rationale
Encouraging the client to push with the next contraction would be contraindicated and detrimental. The action of pushing would increase intra-abdominal pressure and directly force the presenting fetal part down onto the prolapsed cord, leading to maximal compression of the umbilical artery and vein. This would cause severe, sustained fetal bradycardia and hypoxemia, dramatically increasing the risk of fetal demise or severe injury.
Choice G rationale
Applying sterile gauze soaked in normal saline to the exposed cord helps to prevent drying of the Wharton's jelly and umbilical vessels, which minimizes vasospasm and maintains blood flow until delivery. Although important for cord preservation, this intervention is secondary to the immediate mechanical relief of compression (Choice D), which addresses the acute life-threatening fetal compromise from lack of blood flow.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","F"]
Explanation
Choice A rationale
Magnesium sulfate is a central nervous system depressant used to prevent seizures in preeclampsia. Being alert and oriented × 4 is a normal finding and indicates the drug is working at a therapeutic level without causing excessive CNS depression. Normal therapeutic serum magnesium is typically 4-7 mg/dL; this assessment finding indicates appropriate mentation.
Choice B rationale
Absent deep tendon reflexes (DTRs) indicate a loss of reflex excitability due to excessive neuromuscular blockade from hypermagnesemia, representing a major sign of magnesium toxicity. This finding suggests a dangerously high serum magnesium level (>8 mg/dL) and indicates immediate intervention is required to prevent profound respiratory depression and cardiac arrest.
Choice C rationale
A serum magnesium value of 6 mg/dL is within the normal therapeutic range of 4-7 mg/dL for preeclampsia management. This level is effective for seizure prophylaxis without typically causing severe signs of toxicity like respiratory depression or absent reflexes. Therefore, a level of 6 mg/dL does not warrant immediate discontinuation of the infusion.
Choice D rationale
A urine output of 10 mL/hr is significantly below the acceptable minimum of 30 mL/hr (or 100 mL/4 hours) for a client receiving magnesium sulfate. Magnesium is primarily excreted by the kidneys, and oliguria leads to drug accumulation, rapidly increasing the risk of magnesium toxicity. Decreased urine output requires immediate cessation of the infusion and potentially administration of an antidote.
Choice E rationale
A Glasgow Coma Scale (GCS) of 10 indicates a moderate neurological impairment, but it is not specific to magnesium toxicity. While a score below 8 would indicate severe CNS depression requiring immediate intubation, a score of 10 alone, without corroborating signs like absent DTRs or respiratory depression, does not immediately necessitate stopping the infusion, as it could relate to the underlying disease.
Choice F rationale
A respiratory rate of 10 breaths per minute is considered bradypnea and is a critical sign of impending respiratory depression, a life-threatening complication of severe magnesium toxicity. Magnesium depresses the respiratory center and paralyzes respiratory muscles at very high levels (>12 mg/dL). Infusion must be stopped immediately, and the antidote (calcium gluconate) must be prepared.
Correct Answer is D
Explanation
Choice A rationale
The "taking-in" phase, lasting the first 24-48 hours postpartum, is characterized by the mother's focus on her own needs (rest, food, fluid), often passively relying on others and reliving the birth experience. The statement about accepting the outcome and focusing on health indicates a move beyond this initial self-focus and is not the primary reflection.
Choice B rationale
The "taking-hold" phase, typically starting 2-3 days postpartum and lasting several weeks, involves the mother assuming responsibility for infant care and focusing on regaining control over her body and mothering skills. The client's statement focuses on the emotional resolution of the birth experience rather than the active mastery of mothering tasks.
Choice C rationale
The term "working-through" is not a formally recognized phase in the classic maternal adjustment theories (Rubin/Mercer). While emotional processing is necessary, the term doesn't accurately describe the specific developmental stage of letting go of the idealized birth plan and accepting the reality.
Choice D rationale
The "letting-go" phase, which is the final stage of maternal adjustment, involves the mother mourning the loss of the idealized or fantasized birth experience (e.g., natural childbirth) and accepting the reality of the birth and her new parental role. The client's statement of "glad that she and her baby are healthy" after hoping for a different birth perfectly reflects this cognitive and emotional resolution and acceptance.
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