The nurse notices a decreased fetal heart rate (FHR) on the fetal monitor tracing and contacts the charge nurse. The charge nurse completes a vaginal exam and can feel a portion of the umbilical cord in the vagina.
Which emergency interventions will the charge nurse implement? Select all that apply.
Prepare the client for emergency cesarean delivery
Position the client in a knee-chest position and call for help
Locate and insert a vacuum suction catheter into the vagina and push the infant back into the uterus
Keep a gloved hand in the vagina and push upward on the presenting part to keep it off the cord
Contact the provider and report a prolapsed umbilical cord
Correct Answer : A,B,D,E
A. Preparing the client for emergency cesarean delivery is often necessary when a prolapsed umbilical cord is identified.
B. Positioning the client in a knee-chest position helps alleviate pressure on the umbilical cord, improving fetal oxygenation.
C. Inserting a vacuum suction catheter into the vagina and pushing the infant back into the uterus is not a recommended intervention for a prolapsed umbilical cord; this action may cause harm to the fetus.
D. Keeping a gloved hand in the vagina and pushing upward on the presenting part helps relieve pressure on the umbilical cord.
E. Contacting the provider and reporting a prolapsed umbilical cord is essential for prompt communication and decision-making.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Low forceps and mid-forceps deliveries are not typically chosen for clients with active genital herpes due to the risk of exposing the baby to the virus during passage through the birth canal.
B. While vaginal birth is the preferred mode of delivery in many cases, active genital herpes may increase the risk of neonatal transmission, and a cesarean section may be recommended to reduce this risk.
C. Cesarean section is often recommended for clients with active genital herpes to minimize the risk of neonatal transmission, especially if lesions are present at the time of delivery.
D. Mid-forceps delivery is not typically chosen for clients with active genital herpes due to the risk of exposing the baby to the virus during passage through the birth canal.
Correct Answer is D
Explanation
A. A FHR baseline of 125 is within the normal range for a fetal heart rate.
B. A temperature of 99.9°F is a mild elevation and may not be an immediate concern.
C. Blood pressure of 142/90 may be elevated but may not require immediate action unless associated with other concerning symptoms.
D. Contractions lasting 45-60 seconds are prolonged and may lead to decreased fetal oxygenation. This finding should be reported immediately to the charge nurse.
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