A nurse is assisting with the care of a client in active labor. The nurse observes clear fluid and a loop of pulsating umbilical cord outside the client's vagina. Which of the following actions should the nurse perform first?

Assist in initiating IV access and administering IV fluid bolus

Call for assistance immediately

Apply finger pressure to the presenting part

Administer oxygen at 10 L/min via a nonrebreather

Answer and Explanation

The Correct Answer is B

A. Assist in initiating IV access and administering IV fluid bolus: While IV fluids may be needed, the priority in this case is to address the umbilical cord prolapse, which poses an immediate risk to the baby.

B. Call for assistance immediately: Cord prolapse is an obstetric emergency that requires immediate assistance to prevent fetal hypoxia. Rapid response is crucial to save the baby.

C. Apply finger pressure to the presenting part: Although applying pressure to relieve compression on the cord is necessary, the first action should be to summon help to manage the emergency.

D. Administer oxygen at 10 L/min via a nonrebreather: Oxygen is important to improve maternal and fetal oxygenation, but calling for help is the immediate priority in this life-threatening situation.

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Correct Answer is C

Explanation

A. Encouraging the client to rest between contractions: While resting between contractions is important, it is not directly related to the gate control theory of pain, which involves blocking pain signals.

B. Turning the client onto her left side. Positioning can help with circulation and comfort, but it does not directly reflect the gate control theory of pain.

C. Massaging the client's back. The gate control theory suggests that non-painful stimuli, such as massage, can "close the gate" to painful stimuli and help reduce the sensation of pain.

D. Administering prescribed analgesic medication: While medications help relieve pain, they are not based on the gate control theory, which focuses on physical interventions to block pain signals.

A. Wipe from the back to front when performing perineal hygiene B. Keep a daily record of fetal kick counts. C. Avoid bubble bath solution when taking a tub bath. D. Use a condom with sexual intercourse.

Correct Answer is B

Explanation

A. Wipe from the back to front when performing perineal hygiene: The correct method for perineal hygiene is to wipe front to back to reduce the risk of introducing bacteria into the vaginal area, especially in a client with PROM who is at risk for infection.

B. Keep a daily record of fetal kick counts: Monitoring fetal kick counts helps assess fetal well-being, particularly in a high-risk pregnancy like PROM at 26 weeks. It helps detect potential fetal distress early.

C. Avoid bubble bath solution when taking a tub bath: While avoiding bubble bath may help prevent irritation or infection, tub baths should be avoided entirely in cases of PROM to reduce the risk of ascending infection.

D. Use a condom with sexual intercourse. Sexual intercourse is contraindicated in clients with PROM due to the risk of infection.

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A nurse is assisting with the care of a client in active labor. The nurse observes clear fluid and a loop of pulsating umbilical cord outside the client's vagina. Which of the following actions should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client who has premature rupture of membranes at 26 weeks of gestation. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

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