A nurse is admitting a client who is at 38 weeks of gestation following a spontaneous rupture of membranes. The nurse performs a vaginal examination and palpates the umbilical cord. Which of the following actions should the nurse take?
Request that the provider insert an intrauterine pressure catheter.
Exert continuous upward pressure on the presenting part.
Initiate oxytocin via continuous IV infusion.
Place the client in the left-lateral position.
The Correct Answer is B
Choice A rationale:
Requesting that the provider insert an intrauterine pressure catheter is not the immediate action the nurse should take when the umbilical cord is palpated during a vaginal examination. The priority is to relieve pressure on the cord and improve fetal oxygenation.
Choice B rationale:
Exerting continuous upward pressure on the presenting part is the correct action when the nurse palpates the umbilical cord during a vaginal examination. This manoeuvre is called "vaginal elevation,”. helps lift the presenting part off the umbilical cord, reducing the risk of cord compression and fetal distress until the provider can take further action.
Choice C rationale:
Initiating oxytocin via continuous IV infusion is not appropriate when the umbilical cord is palpated during a vaginal examination. Oxytocin can cause uterine contractions, potentially further compromising the cord and fetus.
Choice D rationale:
Placing the client in the left-lateral position is not the best immediate action for cord palpation. While the left-lateral position is useful for relieving pressure on the vena cava in cases of supine hypotensive syndrome, the priority here is to relieve cord compression, and upward pressure on the presenting part is more effective.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Determining gestational age in the first trimester is a common and important use of ultrasound. It helps confirm the estimated due date and monitor the fetus's growth and development.
Choice B rationale:
Performing a biophysical profile in the first trimester is not a common use of ultrasound. Biophysical profiles are usually performed in the second or third trimester to assess fetal well-being.
Choice C rationale:
Observing placental maturity in the first trimester is not a standard use of ultrasound. Placental maturity is typically assessed later in pregnancy, especially in the third trimester.
Choice D rationale:
Detecting intrauterine growth restriction in the first trimester is not a primary use of ultrasound. Intrauterine growth restriction is more commonly assessed in the later stages of pregnancy when fetal growth is a concern.
Correct Answer is C
Explanation
Choice A rationale:
Scant, bright red spotting during early pregnancy can be a normal finding known as implantation bleeding, which occurs when the embryo attaches to the uterus. It is generally not a cause for concern unless it becomes heavy and is accompanied by severe pain.
Choice B rationale:
Elevated hCG (human chorionic gonadotropin) levels during the first trimester are a normal part of a healthy pregnancy. hCG levels peak around 10-12 weeks of gestation and then gradually decrease. A consistent increase in hCG levels is usually a positive sign of a progressing pregnancy.
Choice C rationale:
Cervical dilation during the first trimester, especially when the client is only at 12 weeks of gestation, is not normal and may indicate an imminent spontaneous abortion (miscarriage). This finding should be reported promptly to the healthcare provider for further assessment and management.
Choice D rationale:
Slight abdominal cramps can be a normal symptom during early pregnancy as the uterus undergoes changes and expands. However, unless they are severe and accompanied by other concerning signs such as heavy bleeding, they are not necessarily indicative of an imminent spontaneous abortion.
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