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?

Choice A rationale

Applying witch hazel compresses (often in the form of Tucks pads) is an effective and common intervention for episiotomy discomfort. Witch hazel possesses astringent and anti-inflammatory properties that can reduce swelling, soothe irritation, and promote healing of the perineal tissues, providing significant pain relief for the postpartum client.

Choice B rationale

Administering aspirin is generally contraindicated in the immediate postpartum period, especially if there is any risk of bleeding or if the client is breastfeeding. Aspirin can inhibit platelet aggregation, increasing the risk of postpartum hemorrhage. Safer analgesics, such as NSAIDs like ibuprofen, or acetaminophen, are preferred for pain relief.

Choice C rationale

Having the client use a warm pack is generally not recommended for immediate episiotomy discomfort. While warmth can be soothing, a warm pack can increase blood flow to the area, potentially increasing swelling and discomfort or exacerbating any bleeding in the immediate postpartum period. Cold applications are typically preferred initially.

Choice D rationale

Instructing the client to sit on a soft pillow may provide some comfort by distributing pressure, but it does not directly address the underlying pain and inflammation from the episiotomy. While it can be a supportive measure, it is not as therapeutically effective as direct interventions like cold packs, witch hazel, or appropriate analgesia. .

Choice A rationale

Lubricating the bulb syringe with sterile water is unnecessary and could introduce fluid into the newborn's airway or mouth, potentially causing aspiration. The bulb syringe is designed for mechanical suctioning and does not require lubrication for effective and safe use in clearing secretions from the newborn's mouth and nose.

Choice B rationale

Depressing the bulb prior to insertion creates a negative pressure or vacuum within the syringe. This action allows for effective suctioning of secretions when the bulb is released after insertion into the newborn's mouth or nose, ensuring that mucus is drawn into the syringe for removal.

Choice C rationale

Placing the bulb in the center of the newborn's mouth could stimulate the gag reflex, potentially causing vomiting or aspiration of secretions. The bulb syringe should be inserted into the side of the newborn's mouth, between the cheek and gums, to facilitate effective suctioning without triggering an adverse response.

Choice D rationale

Suctioning the newborn's nose first, then the mouth, is an incorrect sequence. The mouth should always be suctioned first to prevent the newborn from aspirating any oral secretions into the lungs if they gasp or inhale after nasal suctioning, ensuring a clear airway before nasal passages are addressed.