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 C
Explanation
A. Painful intercourse: Painful intercourse can have various causes, but it is not typically associated with serious complications related to oral contraceptives. It may be addressed with the healthcare provider during a routine follow-up.
B. Vaginal itching: Vaginal itching may be due to various reasons, including infections, but it is not typically a direct side effect of oral contraceptives. However, if the itching is persistent or severe, the client should report it to the provider for appropriate evaluation.
C. Persistent headaches: Persistent headaches can be a concerning side effect associated with the use of oral contraceptives. It may indicate an increased risk of vascular events, such as stroke or thrombosis. Clients experiencing persistent headaches while on oral contraceptives should report this symptom to the healthcare provider immediately for further evaluation.
D. Breast tenderness: Breast tenderness is a common side effect of hormonal contraceptives, and it is not typically an emergency or a sign of serious complications. However, if the breast tenderness is severe or associated with other concerning symptoms, the client should contact the provider for guidance.
Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}
Explanation
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