What is the priority nursing intervention for a patient experiencing umbilical cord prolapse during labor?

Performing a cervical exam to assess dilation.

Increasing the rate of intravenous fluids.

Administering oxygen to the mother.

Repositioning the mother to a knee-chest position.

Answer and Explanation

The Correct Answer is D

Choice A rationale

While assessing cervical dilation is important for understanding the progress of labor, it is not the priority intervention in the case of umbilical cord prolapse. The immediate danger is fetal oxygen deprivation due to compression of the prolapsed cord. Delaying intervention to perform a cervical exam could worsen fetal hypoxia.

Choice B rationale

Increasing the rate of intravenous fluids might be indicated to support maternal blood pressure and placental perfusion, but it does not directly address the immediate problem of cord compression. The priority is to relieve pressure on the umbilical cord to restore fetal oxygen supply.

Choice C rationale

Administering oxygen to the mother is a helpful supportive measure to increase the oxygen available to the fetus. However, it does not directly relieve the compression on the umbilical cord, which is the immediate life-threatening situation for the fetus.

Choice D rationale

Repositioning the mother to a knee-chest position (or Trendelenburg) uses gravity to help relieve pressure on the prolapsed umbilical cord by moving the presenting part of the fetus away from the pelvis. This is the priority nursing intervention as it directly aims to improve fetal oxygenation by reducing cord compression until the fetus can be delivered. .

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale

True labor is characterized by progressive cervical changes, including effacement (thinning) and dilation (opening) of the cervix. These changes are the most definitive signs that a woman is in true labor, as contractions can sometimes be Braxton Hicks contractions, which do not cause cervical change.

Choice B rationale

The station of the presenting part (how far down the baby's head is in the pelvis) can change during true labor as the baby descends. However, a single assessment of station does not definitively indicate true labor, as the baby may have been in a lower position prior to the onset of labor. Cervical changes are a more reliable indicator.

Choice C rationale

Rupture of the membranes (water breaking) can occur before or during true labor, but it is not always the first sign of labor. Some women experience contractions for a period before their membranes rupture, and some may not have their membranes rupture until late in labor or require artificial rupture. Therefore, it is not the most definitive sign of true labor.

Choice D rationale

A pattern of regular contractions that increase in frequency, duration, and intensity is a strong indication of true labor. However, some women may experience irregular contractions (Braxton Hicks) that can be mistaken for early labor. The key differentiator is whether these contractions are causing cervical change, making cervical assessment the most definitive sign.

A. G2, T1, P0, A0, L1. B. G2, T1, P0, A0, L2. C. G2, T1, P1, A0, L1. D. G3, T1, P0, A0, L1.

Correct Answer is A

Explanation

Choice A rationale

G represents gravida, the total number of pregnancies, including the current one (2). T represents term births, the number of pregnancies delivered at 37 weeks gestation or later (1). P represents preterm births, the number of pregnancies delivered between 20 and 36 weeks gestation (0). A represents abortions, the number of pregnancies ending before 20 weeks gestation (0). L represents living children (1).

Choice B rationale

This option incorrectly states L as 2. The client has one living child from the previous pregnancy.

Choice C rationale

This option incorrectly states P as 1. The client's previous pregnancy was delivered at 38 weeks, which is considered a term birth, not preterm.

Choice D rationale

This option incorrectly states G as 3. The client is currently pregnant with twins, making this her second pregnancy in total.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

What is the priority nursing intervention for a patient experiencing umbilical cord prolapse during labor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not.”. Which of the following should the nurse recognize as a sign of true labor?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

A nurse is caring for a client who is 5 hours postpartum following a vaginal birth of a newborn weighing 9 lb 6 oz (4252 g). The nurse should recognize that this client is at risk for which of the following postpartum complications?

A multigravida client at 31 weeks gestation is admitted with confirmed pre-term labor.As the nurse continues to monitor the client now receiving magnesium sulfate, which assessment findings will the nurse prioritize and report immediately to the RN or health care provider?

A nurse in the emergency department is caring for a group of clients. Which of the following clients should the nurse plan to see first?

When performing a Non-Stress test, the nurse interprets the finding of two accelerations of the fetal heart rate of 15 beats per minute above the baseline rate of 135 beats per minute lasting for 15 seconds in 20 minutes.This should be documented as:

A nurse is performing a nonstress test (NST) on a client who is at 36 weeks of gestation and asks "what are you looking for during this test?" Which of the following responses should the nurse make?

The nurse assessing a postpartum client's fundus finds it firm, 2 centimeters above the umbilicus and displaced to the right.What is the most appropriate nursing intervention at this time?

What is the most likely cause for early decelerations in the fetal heart rate (FHR) pattern?

The nurse is managing care of a primigravida at full term who is in the active phase of labor.What should be included in developing the plan of care for this client?