A client who is in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the perineum.
Which action should the nurse perform first?

Place the client in Trendelenburg.

Notify the operating room team.

Administer oxygen via face mask.

Administer a fluid bolus of 500 mL.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Placing the client in Trendelenburg position is the first action as it helps to relieve pressure off the umbilical cord by using gravity to shift the fetus away from the pelvis. This position helps to prevent cord compression and maintain blood flow to the fetus.

Choice B rationale

Notifying the operating room team is important but should be done after immediately addressing the umbilical cord prolapse to prevent fetal hypoxia. Initial physical intervention takes priority.

Choice C rationale

Administering oxygen via face mask is beneficial for the mother and fetus but is not the immediate first action. Positioning the client to relieve pressure off the umbilical cord is more urgent.

Choice D rationale

Administering a fluid bolus of 500 mL can help maintain maternal blood pressure, but it is not the first action. The priority is to reposition the client to prevent cord compression.

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Correct Answer is C

Explanation

Choice A rationale

Gathering supplies for an IV infusion is essential in many cases but not the priority here. Measuring abdominal circumference helps determine if there is abdominal distention indicating a possible blockage, which could suggest a condition like Hirschsprung's disease. Early detection and appropriate intervention are critical, making it the first action.

Choice B rationale

Preparing for anorectal surgery may be necessary if a diagnosis like Hirschsprung’s disease or imperforate anus is confirmed. However, the initial priority is to assess for signs of abdominal distention by measuring the circumference, providing crucial information for the next steps.

Choice D rationale

Monitoring strict urinary output is important for overall fluid balance and identifying complications related to fluid shifts. However, in this scenario, the priority action is to assess for abdominal distention, a potential sign of a serious underlying condition causing the symptoms observed in the infant.

A. Infants can receive antibodies through breast milk that help fight infections. B. The infant's immune system may be immature in protecting against infections. C. Immunity in the first months of life provides protection. D. Active immunity in newborns is fully developed in the first month of life.

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

Breast milk contains antibodies, specifically Immunoglobulin A (IgA), which provide passive immunity to infants and help in fighting off infections. This protective mechanism is especially important in the early months when the infant's immune system is still developing.

Choice B rationale

The immune system of a newborn is immature, particularly in its ability to produce its own antibodies. This immaturity means that newborns rely on passive immunity from the mother, either through the placenta during pregnancy or via breast milk after birth.

Choice C rationale

Infants possess passive immunity during the first few months of life, derived from maternal antibodies transferred through the placenta. This temporary immunity provides a crucial defense against infections until the infant's own immune system becomes more developed and capable of responding to pathogens.

Choice D rationale

While newborns have some level of immune function, it is not fully developed within the first month of life. Active immunity, the body's ability to produce its own antibodies in response to pathogens, takes several months to fully mature. .

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A client who is in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the perineum. Which action should the nurse perform first?

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Naxlex Comprehensive Predictor Exams

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A client who is in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the perineum.
Which action should the nurse perform first?