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 D
Explanation
The correct answer is D. Cover the client with warm blankets.
Choice A rationale:
Shaking chills are not always associated with fever, especially during the immediate postpartum period. While determining the client's temperature can rule out infection, this action does not provide immediate relief or comfort. The chills are often physiological due to hormonal and vascular changes.
Choice B rationale:
Seizure precautions are unnecessary unless additional symptoms, such as loss of consciousness or convulsions, are observed. Shaking chills are typically not indicative of a neurological event but rather a normal postpartum response.
Choice C rationale:
Notifying the charge nurse is unnecessary unless the shaking is accompanied by other abnormal findings, such as fever or prolonged chills. The immediate priority is to ensure client comfort.
Choice D rationale:
Providing warm blankets addresses the primary issue of discomfort caused by postpartum chills. This is a standard intervention to stabilize the client's body temperature and promote comfort. The action is immediate, non-invasive, and effective.
Correct Answer is C
Explanation
Choice A rationale :
Scrambled eggs. Taking ferrous sulfate with scrambled eggs is not the optimal choice because eggs contain phytates, which can bind to iron and reduce its absorption. Therefore, it may hinder the effectiveness of the iron supplement, and the client may not receive the full benefit of the medication.
Choice B rationale
A high-fibre meal. While fiber is generally beneficial for digestion and overall health, it is not the best choice to take with ferrous sulfate. Fiber can also interfere with iron absorption in the same way as phytates, potentially reducing the medication's effectiveness.
Choice C rationale
Orange juice. The nurse should instruct the client to take the ferrous sulfate with orange juice. Orange juice is an excellent choice because it is rich in vitamin C. Vitamin C enhances the absorption of non-heme iron (the type of iron found in plant-based sources like ferrous sulfate). By taking the medication with orange juice, the client can maximize the absorption of iron and improve the treatment of iron-deficiency anaemia.
Choice D rationale
Milk. Consuming ferrous sulfate with milk is not advisable. Calcium, present in milk, can inhibit the absorption of iron. Therefore, taking the medication with milk might reduce the efficacy of the iron supplement and not provide the desired therapeutic effect.
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