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
A. Fetal heart rate 152/min: Fetal heart rate is not typically considered an adverse effect of epidural analgesia. The focus of epidural analgesia is on providing pain relief for the mother rather than directly affecting the fetal heart rate.
B. Hypotension: Hypotension (low blood pressure) is a common adverse effect of epidural analgesia. Epidural anesthesia can cause vasodilation, leading to a decrease in blood pressure. The nurse should monitor the client's blood pressure closely and administer interventions as needed, such as IV fluids or medications to address hypotension.
C. Polyuria: Polyuria (excessive urination) is not a direct adverse effect of epidural analgesia. Epidural analgesia primarily affects pain sensation rather than urinary function.
D. Maternal temperature of 37.4 C (99.4 F): A slightly elevated maternal temperature is not a common adverse effect of epidural analgesia. However, the nurse should monitor for signs of infection or other complications and report any significant temperature changes to the healthcare provider.
Correct Answer is B
Explanation
. Protective environment: Protective environment precautions are used for clients with compromised immune systems, such as those undergoing stem cell transplantation. This precaution aims to protect the client from exposure to environmental pathogens.
B. Contact: This is the correct answer. Contact Precautions are appropriate for clients with C. difficile infection. The precautions include using gloves and gowns when entering the room and ensuring proper hand hygiene to prevent the transmission of the bacteria.
C. Droplet: Droplet precautions are used for diseases that are transmitted through respiratory droplets, such as influenza or pertussis. C. difficile is not primarily transmitted through respiratory droplets.
D. Airborne: Airborne precautions are used for diseases that can be transmitted by tiny particles suspended in the air, such as tuberculosis or chickenpox. C. difficile is not transmitted through the airborne route.
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