A nurse is caring for a client who is in labor and has 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
Wrap the cord in a sterile towel and moisten with warm sterile normal saline
Apply oxygen via facemask to the client
The Correct Answer is A
A. Use fingers to exert upward pressure on the presenting part
The priority in the case of a prolapsed umbilical cord is to relieve pressure on the cord to maintain blood flow to the fetus. The nurse should use sterile-gloved fingers to lift the presenting part of the fetus off the prolapsed cord. This action helps prevent compression of the umbilical cord, which could lead to fetal hypoxia and distress.
B. Administer a tocolytic medication: Tocolytic medications are used to inhibit uterine contractions. While tocolytics might be used in certain situations, the immediate concern with a prolapsed cord is to relieve pressure on it to maintain fetal blood flow.
C. Wrap the cord in a sterile towel and moisten with warm sterile normal saline: While covering the cord with a sterile towel and moistening it can help prevent drying and protect the cord, it is not the first priority. The primary concern is relieving pressure on the cord to prevent fetal compromise.
D. Apply oxygen via facemask to the client: Oxygen administration is important in managing fetal distress, but it is not the first action to take in the case of a prolapsed umbilical cord. The priority is to relieve pressure on the cord to maintain fetal oxygenation.
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Related Questions
Correct Answer is B
Explanation
Correct Answer: B
B. Administer broad-spectrum antibiotics
Newborns with a leaking myelomeningocele are at a high risk for infection, especially meningitis, due to the exposure of cerebrospinal fluid (CSF). Administering broad-spectrum antibiotics helps reduce the risk of infection until the defect is surgically closed.
Incorrect answers:
A.Monitor the rectal temperature every 4 hr.Taking rectal temperatures is contraindicated in a newborn with a myelomeningocele due to the risk of trauma to the rectum and potential introduction of bacteria near the exposed spinal cord and CSF. Axillary temperatures should be used instead.
C.Prepare for surgical closure after 72 hr.Surgical repair of a myelomeningocele is typically performed within the first 24–48 hours of life to reduce the risk of infection and prevent further nerve damage.
D.Cleanse the site with povidone-iodine. Povidone-iodine is not appropriate for cleansing the exposed myelomeningocele site because it can be too harsh and toxic to neural tissue.
Correct Answer is A
Explanation
A. Hypnosis can be beneficial if you practiced it during the prenatal period
Hypnosis techniques for pain management during labor can indeed be effective if practiced and learned before the onset of labor. Practicing hypnosis techniques during the prenatal period allows the individual to become more familiar with the process, enhancing their ability to use hypnosis as a pain management tool during labor.
B. Hypnosis does not work for controlling pain associated with labor: This statement is inaccurate. While hypnosis might not be effective for everyone, it can be a beneficial technique for managing labor pain in some individuals. It's important not to dismiss its potential efficacy for pain control in labor.
C. Synchronized breathing will be required during hypnosis: While breathing techniques are often incorporated into various pain management strategies during labor, such as in childbirth education classes or relaxation techniques, the requirement for synchronized breathing specifically during hypnosis is not universally accurate. Hypnosis techniques can vary, and they might or might not involve synchronized breathing.
D. Focusing on controlling body functions will be helpful during hypnosis: Hypnosis typically involves relaxation and focus but not necessarily the conscious control of body functions. The emphasis in hypnosis is often on relaxation, mental imagery, and suggestion rather than active control of physiological functions.
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