The nurse is performing a vaginal assessment on a patient in labor and notices the umbilical cord protruding from the vagina. What is the priority nursing action with this finding?
Administer oxygen to the client via a nonrebreather mask at 10L/min.
Place a rolled towel beneath one of the client's hips.
Apply internal upward pressure to the presenting part using two gloved fingers.
Increase the IV infusion rate to provide a fluid bolus.
The Correct Answer is C
A. Administering oxygen via a nonrebreather mask is incorrect as the priority action. Although oxygen can improve fetal oxygenation, it does not directly relieve compression of the umbilical cord, which is the immediate, life-threatening issue in a prolapsed cord. Oxygen may be used after cord compression is relieved, but it is not the first intervention.
B. Placing a rolled towel beneath one of the client’s hips is incorrect because this action alone is insufficient to relieve pressure on the umbilical cord. While positioning such as Trendelenburg or knee-chest may help reduce cord compression, the most immediate and effective intervention is manual elevation of the presenting part.
C. Applying internal upward pressure to the presenting part using two gloved fingers is correct because this action immediately relieves pressure on the prolapsed umbilical cord, restoring fetal blood flow and oxygenation. The nurse must maintain this pressure continuously until the patient is taken for emergency delivery, usually by cesarean section. This is the highest priority life-saving intervention.
D. Increasing the IV infusion rate to provide a fluid bolus is incorrect because fluids do not address the mechanical compression of the umbilical cord. Although IV fluids may be part of overall management, they do not correct the acute cause of fetal hypoxia in cord prolapse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The development of pubic hair is incorrect as the first sign of puberty in most females. Pubic hair usually appears after the onset of breast development and is part of adrenarche, which occurs later in puberty.
B. Breast development is correct. The initial sign of female puberty is thelarche, or the development of breast buds, typically occurring between 8 and 13 years of age. Breast development signals the beginning of gonadarche, the activation of the hypothalamic-pituitary-ovarian axis.
C. The onset of menstruation is incorrect because menarche usually occurs 2–2.5 years after breast development. Menarche indicates more advanced pubertal development rather than the first sign.
D. The growth spurt is incorrect because although girls experience a rapid increase in height during puberty, the growth spurt usually occurs after breast budding begins, not before.
Correct Answer is B
Explanation
A. Visual Analog Scale (VAS) is incorrect because it requires the child to understand and mark a point on a line to represent pain intensity, which is often too complex for a 4-year-old, especially if they cannot verbalize pain reliably.
B. FLACC scale is correct. The FLACC (Face, Legs, Activity, Cry, Consolability) scale is an observational tool designed for children who cannot self-report pain. It assesses behavioral and physiological indicators of pain including facial expression, leg movement, activity level, crying, and consolability. Scores range from 0 to 10, allowing for objective assessment and monitoring of pain in young children, infants, or nonverbal patients.
C. Faces Pain Scale is incorrect because it relies on the child’s ability to understand and point to a facial expression that represents their pain. While appropriate for some preschoolers, a 4-year-old who cannot reliably verbalize or comprehend the scale may not use it accurately.
D. Numeric Rating Scale is incorrect because it requires the child to assign a number (0–10) to describe pain, which is generally suitable for children aged 7 and older who can understand abstract numerical concepts.
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