The nurse suspects umbilical cord prolapse in a patient whose membranes have just ruptured because she notes which assessment finding?
A sudden increase in fetal heart rate variability
A large amount of clear amniotic fluid
A change in fetal heart rate from 140 to 90 bpm
A loop of umbilical cord protruding from her vagina.
The Correct Answer is D
The correct answer is choice D. A loop of umbilical cord protruding from her vagina. This is a sign of umbilical cord prolapse, which is a medical emergency that occurs when the cord slips past the fetal presenting part and becomes compressed, reducing blood flow and oxygen to the fetus. The nurse should immediately call for help, place the woman in a knee-chest or Trendelenburg position, insert two fingers into the vagina and lift the presenting part off the cord, cover the cord with sterile saline-soaked gauze, administer oxygen, and prepare for an emergency cesarean delivery.
Choice A is wrong because a sudden increase in fetal heart rate variability is not a specific sign of cord prolapse. It may indicate fetal well-being or distress depending on the pattern and duration of the variability.
Choice B is wrong because a large amount of clear amniotic fluid is not a sign of cord prolapse. It may indicate rupture of membranes, which is a risk factor for cord prolapse if the presenting part is not engaged.
Choice C is wrong because a change in fetal heart rate from 140 to 90 bpm is not a sign of cord prolapse. It may indicate fetal bradycardia, which can have many causes such as hypoxia, acidosis, medication effects, or fetal sleep cycle.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
The correct answer is choice B, C, D and E.These are all fetal presentations that increase a patient’s risk for umbilical cord prolapse.Umbilical cord prolapse is when the umbilical cord comes out of the uterus with or before the presenting part of the baby.This can cause fetal hypoxia and brain damage due to cord compression.
Choice A is wrong because vertex presentation is the most common and normal fetal position, where the head is down and fully flexed.
This does not increase the risk of cord prolapse.
Normal ranges for fetal presentation are:
• Vertex: 95% of term deliveries.
• Breech: 3% to 4% of term deliveries.
• Transverse lie: 0.5% of term deliveries.
• Face: 0.2% of term deliveries.
• Brow: 0.1% of term deliveries.
Correct Answer is D
Explanation
The correct answer is choice D. A loop of umbilical cord protruding from her vagina.This is a sign of umbilical cord prolapse, which is a medical emergency that occurs when the cord slips past the fetal presenting part and becomes compressed, reducing blood flow and oxygen to the fetus.The nurse should immediately call for help, place the woman in a knee-chest or Trendelenburg position, insert two fingers into the vagina and lift the presenting part off the cord, cover the cord with sterile saline-soaked gauze, administer oxygen, and prepare for an emergency cesarean delivery.
Choice A is wrong because a sudden increase in fetal heart rate variability is not a specific sign of cord prolapse.It may indicate fetal well-being or distress depending on the pattern and duration of the variability.
Choice B is wrong because a large amount of clear amniotic fluid is not a sign of cord prolapse.It may indicate rupture of membranes, which is a risk factor for cord prolapse if the presenting part is not engaged.
Choice C is wrong because a change in fetal heart rate from 140 to 90 bpm is not a sign of cord prolapse.It may indicate fetal bradycardia, which can have many causes such as hypoxia, acidosis, medication effects, or fetal sleep cycle.
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