A nurse is assisting with the care of a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse take first?
Prepare the client for an emergency cesarean birth.
Explain to the client what is happening.
Cover the cord with a sterile, moist saline dressing.
Place the client in a knee-chest or Trendelenburg position.
The Correct Answer is D
The correct answer is choice d. Place the client in a knee-chest or Trendelenburg position.
Choice A rationale:
Preparing the client for an emergency cesarean birth is important, but it is not the immediate first action. The priority is to relieve pressure on the umbilical cord to prevent fetal hypoxia.
Choice B rationale:
Explaining to the client what is happening is important for communication and reassurance, but it is not the immediate first action. Immediate physical intervention is required to prevent harm to the fetus.
Choice C rationale:
Covering the cord with a sterile, moist saline dressing is a necessary step to prevent the cord from drying out and to reduce infection risk, but it should be done after repositioning the client to relieve pressure on the cord.
Choice D rationale:
Placing the client in a knee-chest or Trendelenburg position helps to relieve pressure on the umbilical cord, which is crucial to maintain fetal oxygenation. This is the immediate first action to take in this emergency situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["6"]
Explanation
The Apgar s core is a s coring s ys tem doctors and nurs es us e to as s es s newborns after they’re born. The Apgar s coring s ys tem is divided into five categories : Activity, Puls e, Grimace, Appearance, and Res piration. Each category receives a s core of 0 to 2 points 1.
Bas ed on the information you provided, the newborn’s 1-min Apgar s core would be calculated as follows :
• Activity: s ome flexion of extremities = 1 point
• Puls e: heart rate 110/ min = 2 points
• Grimace: grimace in res pons e to s uctioning of the nares = 1 point
• Appearance: body pink in color with blue extremities = 1 point
• Res piration: s low, weak cry = 1 point
Adding up the points for each category, the newborn’s 1-min Apgar s core would be 6.
Correct Answer is B
Explanation
Choice A rationale:
Hypotension is not an expected finding in a client with severe preeclampsia. In preeclampsia, the client typically experiences hypertension (high blood pressure) rather than hypotension (low blood pressure). Hypotension may be concerning as it could indicate inadequate perfusion to vital organs.
Choice B rationale:
Headache is an expected finding in a client with severe preeclampsia. Headaches are a common symptom of preeclampsia and are often described as persistent and severe. They can result from increased blood pressure and possibly cerebral oedema.
Choice C rationale:
Tachycardia is not an expected finding in a client with severe preeclampsia. Tachycardia refers to an abnormally fast heart rate, but in preeclampsia, bradycardia (abnormally slow heart rate) or a normal heart rate is more typical. Tachycardia could indicate other underlying issues.
Choice D rationale:
Polyuria is not an expected finding in a client with severe preeclampsia. Polyuria is characterized by excessive urination, and in preeclampsia, the opposite may occur due to decreased kidney perfusion, resulting in oliguria (reduced urine output).
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