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 D
Explanation
Choice A rationale:
Telangiectatic nevi are commonly known as "stork bites”. or "angel kisses”. and are superficial vascular areas commonly found on the nape of the neck or the eyelids of newborns? These are benign and pose no significant health risks.
Choice B rationale:
Erythema toxicum is a common, benign skin rash that appears in the first few days of life. It presents as small, raised red spots with a surrounding halo and is not related to a nuchal cord.
Choice C rationale:
Periauricular papillomas, also known as "ear tags,”. are small, skin-coloured nodules that can be found near the external ear. They are also benign and unrelated to a nuchal cord.
Choice D rationale:
Facial petechiae are tiny, red or purple pinpoint spots on the skin caused by minor haemorrhages. In newborns, facial petechiae can be associated with a nuchal cord, which is a condition where the umbilical cord is wrapped around the baby's neck during delivery. This condition is relatively common and usually resolves without complications. The nurse should monitor the baby for any signs of distress or complications related to the nuchal cord.
Correct Answer is A
Explanation
Choice A rationale:
The Moro reflex, also known as the startle reflex, is elicited by making a loud noise above the newborn, causing them to extend their arms and legs and then bringing them back to the body in a hugging motion. This reflex is a normal developmental response in term newborns.
Choice B rationale:
Touching the newborn's cheek with a finger elicits the rooting reflex, where the newborn turns their head toward the stimulus, searching for a nipple or object to suck. It is a different reflex and not the Moro reflex.
Choice C rationale:
Tapping the newborn's forehead with a finger does not elicit any specific reflex. This action is not related to the Moro reflex.
Choice D rationale:
Turning the newborn's head to one side elicits the asymmetric tonic neck reflex (ATNR), not the Moro reflex. In ATNR, when the head is turned to one side, the arm on that side extends while the opposite arm flexes.
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