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 D

Explanation

Choice A rationale

Group therapy can be beneficial for individuals with substance abuse issues as it provides support, reduces isolation, and promotes healthy coping mechanisms. However, it is not the primary intervention for ensuring the health of the baby in a pregnant client on methadone.

Choice B rationale

Discontinuing methadone abruptly is dangerous and can lead to withdrawal symptoms, which can harm both the mother and the fetus. It is important to continue methadone treatment under medical supervision to prevent complications.

Choice C rationale

Genetic testing protocols are important for identifying potential genetic disorders but do not directly address the immediate health needs of a baby born to a mother on methadone treatment.

Choice D rationale

Starting a prenatal care plan as soon as possible is crucial for monitoring the health and development of the fetus, managing the mother's methadone treatment, and providing necessary interventions to ensure the baby's well-being. It is the best approach to ensure a healthy pregnancy.

A. Give zidovudine 6 to 12 hours after birth. B. Administer antibiotics for 7 to 10 days. C. Delay the initial bath for 1 to 2 days. D. Encourage breastfeeding every 2 to 3 hours.

Correct Answer is A

Explanation

Choice A rationale

Giving zidovudine 6 to 12 hours after birth is crucial as it helps prevent mother-to-child transmission of HIV. Early administration of antiretroviral medication reduces the risk of the newborn acquiring HIV significantly.

Choice B rationale

Administering antibiotics for 7 to 10 days is not standard practice for newborns of HIV-positive mothers unless there is an indication of infection. The primary intervention is antiretroviral therapy.

Choice C rationale

Delaying the initial bath for 1 to 2 days is not standard practice for preventing HIV transmission. It is important to bathe the newborn shortly after birth to remove any potential HIV-containing fluids.

Choice D rationale

Encouraging breastfeeding every 2 to 3 hours is not advised for HIV-positive mothers as HIV can be transmitted through breast milk. Alternatives such as formula feeding are recommended to prevent transmission. .

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is speaking with a client who is addicted to heroin and who just learned that she is pregnant. The client states, "I just started taking methadone. Is there anything else I can do to make sure my baby is healthy?" Which information should the nurse provide?

Correct Answer is D

Explanation

A newborn is delivered by cesarean section to a mother who is HIV-positive. The mother received antiretroviral therapy during pregnancy. Which intervention should the nurse implement?

Correct Answer is A

Explanation

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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?