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Nursing interventions and management
Nursing interventions and management ( 4 Questions)
A nurse is caring for a client who is in labor and has a prolapsed umbilical cord.
Which of the following actions should the nurse take first?
Applying a warm, sterile, saline-soaked towel to the visible cord is not the first action to take.This intervention can prevent drying and atrophy of the umbilical vessels, but it does not relieve cord compression.
Administering oxygen at 8 to 10 L/min via a face mask is not the first action to take.This intervention can increase fetal oxygenation, but it does not relieve cord compression.
Calling for assistance and notifying the provider is not the first action to take.This intervention is necessary to prepare for emergency delivery, but it does not relieve cord compression
This position can reduce the pressure of the fetal presenting part on the prolapsed cord and improve fetal oxygenation.The nurse should also call for assistance and notify the provider, administer oxygen at 8 to 10 L/min via a face mask, and apply a warm, sterile, saline-soaked towel to the visible cord, but these are not the first actions to take.
The correct answer is choice D. Reposition the client to a knee-chest position. This is because this position can reduce the pressure of the fetal presenting part on the prolapsed cord and improve fetal oxygenation. The nurse should also call for assistance and notify the provider, administer oxygen at 8 to 10 L/min via a face mask, and apply a warm, sterile, saline-soaked towel to the visible cord, but these are not the first actions to take.
Choice A is wrong because applying a warm, sterile, saline-soaked towel to the visible cord is not the first action to take. This intervention can prevent drying and atrophy of the umbilical vessels, but it does not relieve cord compression.
Choice B is wrong because administering oxygen at 8 to 10 L/min via a face mask is not the first action to take. This intervention can increase fetal oxygenation, but it does not relieve cord compression.
Choice C is wrong because calling for assistance and notifying the provider is not the first action to take. This intervention is necessary to prepare for emergency delivery, but it does not relieve cord compression.
