A nurse is caring for a client who is in labor and has a prolapsed umbilical cord.
Which of the following actions should the nurse take first?
Apply warm saline-soaked gauze to the exposed cord
Place the client in Trendelenburg position
Administer oxygen via face mask at 10 L/min
Call for assistance and prepare for an emergency cesarean delivery
The Correct Answer is D
The correct answer is d. Call for assistance and prepare for an emergency cesarean delivery.
Rationale for Choice d:
- Emergency cesarean delivery is the definitive treatment for a prolapsed umbilical cord. It's crucial to expedite delivery to prevent fetal hypoxia and potential death.
- Any delay in delivery can have catastrophic consequences for the fetus.
- Calling for assistance immediately activates the necessary personnel and resources for a swift cesarean delivery.
- Prompt preparation ensures the operating room, anesthesia team, and surgical team are ready to proceed without delay.
Rationale for Choice a:
- Applying warm saline-soaked gauze to the exposed cord is a temporary measure to prevent cord compression and drying.
- It does not address the underlying issue of cord compression and compromised blood flow to the fetus.
- While this action is important, it should not take precedence over calling for assistance and preparing for emergency delivery.
Rationale for Choice b:
- Placing the client in Trendelenburg position (head down, feet up) was once thought to relieve pressure on the cord.
- However, current evidence does not support this practice.
- It can potentially worsen fetal distress by increasing venous return and cardiac output, leading to increased cord compression.
- It can also make it more difficult to monitor the fetal heart rate and perform a cesarean delivery.
Rationale for Choice c:
- Administering oxygen via face mask at 10 L/min may provide some benefit to the fetus by increasing maternal oxygen saturation.
- However, it does not address the primary issue of cord compression and compromised fetal blood flow.
- It should not be prioritized over calling for assistance and preparing for emergency delivery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. FHR of 80/min with severe variable decelerations.This indicates that the umbilical cord is prolapsed and compressed by the baby’s body, causing a decrease in blood and oxygen supply to the baby.A normal fetal heart rate is between 120 and 160 beats per minute.Severe variable decelerations are abrupt drops in the fetal heart rate that do not correspond to contractions.
Choice A is wrong because FHR of 160/min with accelerations is a normal finding that indicates a healthy baby.Accelerations are temporary increases in the fetal heart rate that usually occur with fetal movement or contractions.
Choice B is wrong because FHR of 120/min with early decelerations is also a normal finding that indicates a well-oxygenated baby.Early decelerations are gradual decreases in the fetal heart rate that mirror contractions and are caused by head compression.
Choice D is wrong because FHR of 140/min with late decelerations is an abnormal finding that indicates uteroplacental insufficiency, not cord prolapse.Late decelerations are gradual decreases in the fetal heart rate that occur after contractions and are caused by reduced blood flow to the placenta.
Correct Answer is A
Explanation
The correct answer is choice A. Push the presenting part upward with gloved fingers.This action can relieve cord compression and improve fetal oxygenation until an emergency cesarean section can be performed.
Choice B is wrong because pulling the cord gently to reduce tension can cause more damage to the umbilical vessels and increase the risk of fetal hemorrhage.
Choice C is wrong because clamping the cord with sterile forceps can cut off the blood supply to the fetus and cause fetal death.
Choice D is wrong because cutting the cord and tying it with sterile string can also cut off the blood supply to the fetus and cause fetal death.
Some additional information:
• A prolapsed umbilical cord is a rare but life-threatening obstetric emergency that occurs when the umbilical cord is abnormally positioned between the fetal presenting part and the cervix.
• The normal range of umbilical cord length is 40 to 60 cm.A longer cord can increase the risk of prolapse.
• The normal range of fetal heart rate is 110 to 160 beats per minute.A prolapsed cord can cause fetal bradycardia (slow heart rate) due to hypoxia.
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