A nurse is assisting a client who is in labor to the bathroom when the client reports a sudden gush of fluid.
The nurse observes an umbilical cord protruding from the client's vagina. Which of the following actions should the nurse take first?

Assist the client into a knee-chest position.

Administer oxygen 10 L/min via face mask.

Apply an external fetal monitor on the client.

Loosely wrap the cord with a saline-saturated towel.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Assisting the client into a knee-chest position, or Trendelenburg, is the priority to alleviate pressure on the prolapsed umbilical cord. This position uses gravity to shift the fetal presenting part off the cord, preventing further compression and preserving umbilical blood flow. Maintaining adequate blood flow is crucial to prevent fetal hypoxia and bradycardia, which can quickly lead to fetal compromise and potential death if uncorrected.

Choice B rationale

Administering oxygen via face mask is a supportive measure for potential fetal hypoxia, but it is secondary to relieving cord compression. While oxygen can improve maternal oxygen saturation and fetal oxygenation, it will not resolve the underlying issue of cord compression. Addressing the mechanical compression of the cord must be the immediate priority to restore adequate blood flow.

Choice C rationale

Applying an external fetal monitor is important for assessing fetal well-being after a cord prolapse. However, it is not the first action. The immediate priority is to relieve pressure on the cord to prevent further fetal compromise. Fetal monitoring provides diagnostic information but does not directly intervene to alleviate the life-threatening compression.

Choice D rationale

Loosely wrapping the cord with a saline-saturated towel is an important step to prevent drying and maintain viability of the exposed cord, but it is not the immediate priority. The primary goal is to relieve pressure on the cord to ensure blood flow to the fetus. Protecting the cord from drying is a subsequent action after addressing the compression.

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Correct Answer is C

Explanation

Choice A rationale

Auscultating bowel sounds is an important assessment, but it is not the first action for a newborn with neonatal abstinence syndrome. Respiratory compromise is a life-threatening complication that requires immediate assessment to ensure adequate oxygenation and ventilation, as respiratory depression can occur due to central nervous system effects of withdrawal.

Choice B rationale

Swaddling can provide comfort and reduce hyperirritability in a newborn with neonatal abstinence syndrome. While beneficial, it is a supportive intervention. Prioritizing physiological stability, specifically respiratory status, is essential before implementing comfort measures to address potentially life-threatening complications.

Choice C rationale

Determining the newborn's respiratory rate is the first action because respiratory depression or distress is a critical and potentially life-threatening symptom of neonatal abstinence syndrome. Accurate assessment of respiratory effort, rate (normal range is 30-60 breaths/minute), and presence of retractions or nasal flaring is paramount to ensure adequate oxygenation and guide immediate interventions.

Choice D rationale

Weighing a wet diaper assesses hydration and urinary output. While important for overall assessment, it is not the immediate priority for a newborn experiencing neonatal abstinence syndrome, as respiratory stability takes precedence due to the direct threat to life that respiratory compromise can pose in these vulnerable infants.

A. Instruct the client to apply warm packs to the perineum every 8 hours. B. Tell the client to apply antibiotic ointment to the perineal area four times per day. C. Explain to the client how to dry her perineum by wiping with toilet tissue after each void. D. Encourage the client to take a sitz bath twice per day.

Correct Answer is D

Explanation

Choice A rationale

Applying warm packs to the perineum is generally discouraged in the immediate postpartum period, especially within the first 24 hours, due to the risk of increasing swelling and discomfort. Cold applications are typically preferred initially to promote vasoconstriction, which helps to reduce edema and numb the area, offering greater pain relief.

Choice B rationale

Routine application of antibiotic ointment to an episiotomy is not standard practice unless there are signs of infection. Episiotomies are clean-contaminated wounds, and prophylactic antibiotic use is generally avoided to prevent the development of antibiotic resistance and disruption of the normal perineal flora. Aseptic wound care is prioritized.

Choice C rationale

Wiping the perineum with toilet tissue after voiding can introduce bacteria from the anal area into the healing episiotomy site, increasing the risk of infection. Perineal care should involve rinsing the area with warm water (e.g., using a peri-bottle) and patting it dry from front to back to minimize bacterial contamination and promote healing.

Choice D rationale

Encouraging the client to take a sitz bath twice per day is beneficial for episiotomy care. The warm water promotes vasodilation, increasing blood flow to the perineal area, which aids in healing and reduces discomfort. It also helps to keep the area clean and can soothe irritated tissues, facilitating recovery.

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A nurse is assisting a client who is in labor to the bathroom when the client reports a sudden gush of fluid. The nurse observes an umbilical cord protruding from the client's vagina. Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a newborn who has neonatal abstinence syndrome. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is caring for a client who is 12 hours postpartum and has an episiotomy. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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A nurse is assisting a client who is in labor to the bathroom when the client reports a sudden gush of fluid.
The nurse observes an umbilical cord protruding from the client's vagina. Which of the following actions should the nurse take first?