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 B
Explanation
Choice A rationale:
Freezing embryos for future use is a personal decision and not something a nurse should instruct a client to avoid.
Choice B rationale:
In vitro fertilization can result in multiple pregnancies, and reduction of multiple fetuses may be necessary for the health of the mother and the remaining fetuses.
Choice C rationale:
The use of donor oocytes is a personal decision and not something a nurse should instruct a client to avoid.
Choice D rationale:
In in vitro fertilization, sperm is introduced to the egg in a laboratory, not the uterus.
Correct Answer is D
Explanation
Choice A rationale:
Placing the client in a semi-Fowler’s position for 1 hr after administration is not necessary.
Choice B rationale:
Allowing the medication to reach room temperature prior to administration is not necessary.
Choice C rationale:
Instructing the client to avoid urinary elimination until after administration is not necessary.
Choice D rationale:
Verifying that informed consent is obtained prior to administration is crucial as it ensures the client is aware of the procedure and its potential risks.
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