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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"A"}}
Explanation
For the findings 24 hours later, the nurse should interpret them as follows:
Urinary output: 40 ml/hr
Interpretation: Sign of potential worsening condition
Explanation: A urinary output of 40 ml/hr is concerning and indicates potential dehydration. It is a sign of potential worsening of the client's condition, as it suggests inadequate fluid intake or ongoing fluid losses.
3+ ketones
Interpretation: Sign of potential worsening condition
Explanation: The presence of 3+ ketones in the urine suggests ongoing ketosis, which can occur in hyperemesis gravidarum due to starvation and the breakdown of fats for energy. It is a sign of potential worsening of the client's nutritional status.
Heart rate: 100/min
Interpretation: Sign of potential improvement
Explanation: A heart rate of 100/min is within the normal range. It can be interpreted as a sign of potential improvement, indicating that the client's cardiovascular system is maintaining an appropriate heart rate.
WBC count: 10,000/mm3
Interpretation: Unrelated to diagnosis
Explanation: The WBC count within the normal range (10,000/mm3) is unrelated to the diagnosis of hyperemesis gravidarum. It does not provide specific information about the client's condition in this context.
Urine specific gravity: 1.050
Interpretation: Sign of potential worsening condition
Explanation: A urine specific gravity of 1.050 is elevated and indicates concentrated urine. This finding is a sign of potential worsening of the client's dehydration status.
Urine pH: 5
Interpretation: Unrelated to diagnosis
Explanation: The urine pH of 5 is within the normal range and is unrelated to the diagnosis of hyperemesis gravidarum. It does not provide specific information about the client's condition in this context.
Correct Answer is D
Explanation
A. This test determines if your baby is at risk for developing hypoglycemia after birth: The indirect Coombs' test is not related to assessing the risk of hypoglycemia in the baby. It specifically focuses on Rh sensitization.
B. The test will determine the amount of amniotic fluid around the fetus: The indirect Coombs' test does not assess the amount of amniotic fluid around the fetus. It is specifically aimed at detecting antibodies in the maternal blood.
C. The test studies blood flow in the fetus and placenta using ultrasound waves: This description is more indicative of a Doppler ultrasound or other tests that assess blood flow. The indirect Coombs' test is a blood test and does not involve ultrasound waves.
D. This test will detect the presence of Rh-positive antibodies in your blood
The indirect Coombs' test is performed during pregnancy to detect the presence of Rh antibodies in the maternal bloodstream. Rh antibodies can develop if an Rh-negative mother is carrying an Rh-positive baby, and there is a risk of hemolytic disease of the newborn (HDN) in subsequent pregnancies. The test helps identify if the mother has developed antibodies against Rh-positive blood, which could potentially affect the fetus.
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