A nurse is caring for a client who is in labor and has a spontaneous rupture of membranes. The nurse notes that the umbilical cord is protruding from the client's vagina.
After calling for help, which of the following actions should the nurse take first?
Use fingers to exert upward pressure on the presenting part.
Administer a tocolytic medication.
Apply oxygen via facemask to the client.
Wrap the cord in a sterile towel and moisten with warm sterile normal saline.
The Correct Answer is A
Choice A rationale:
The nurse should use fingers to exert upward pressure on the presenting part to relieve cord compression, which is the immediate priority in this emergency situation.
Choice B rationale:
Administering a tocolytic medication is not the immediate priority. It may be done later to inhibit uterine contractions.
Choice C rationale:
Applying oxygen to the client is important, but it’s not the first action. The nurse needs to relieve cord compression first.
Choice D rationale:
Wrapping the cord in a sterile towel and moistening with warm sterile normal saline is important, but it’s not the first action. The nurse needs to relieve cord compression first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Hypotension is a common adverse effect of epidural analgesia due to the blockage of sympathetic nerve fibers, which can lead to vasodilation and decreased cardiac output.
Choice B rationale:
Polyuria is not typically associated with epidural analgesia. It could be related to other factors such as fluid administration or underlying medical conditions.
Choice C rationale:
A fetal heart rate of 152/min is within the normal range (110-160 beats/min) and is not an adverse effect of epidural analgesia.
Choice D rationale:
A maternal temperature of 37.4° C (99.4° F) is within the normal range (36.1° C to 37.2° C or 97° F to 99° F) and is not an adverse effect of epidural analgesia.
Correct Answer is C
Explanation
Choice Arationale:
Decreasing the rate of IV fluids would not address the issue of late decelerations, which indicate fetal hypoxia.
Choice Brationale:
Fetal scalp stimulation is used to assess fetal well-being, but it would not address the issue of late decelerations.
Choice C rationale:
Administering oxygen via a face mask can increase the amount of oxygen available to the fetus, potentially alleviating the hypoxia causing the late decelerations.
Choice D rationale:
Elevating the client’s head would not address the issue of late decelerations.
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