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 D
Explanation
A. Applying hydrating lotion to the newborn's skin prior to treatment is not recommended as lotions or creams can interfere with the effectiveness of phototherapy and may increase the risk of skin irritation or burns.
B. Turning the newborn every 4 hours is insufficient; the newborn should be turned more frequently, typically every 2 hours, to ensure even exposure to the phototherapy light and to prevent pressure sores.
C. Provide the newborn with 15 ml glucose water after each feeding: This is not a standard practice related to phototherapy. Feeding frequency and amounts are determined by the infant's age, weight, and feeding readiness, but providing glucose water after each feeding is not a routine recommendation.
D. Close the newborn's eyes before applying eyepatches: This is the correct answer. Eyepatches are used during phototherapy to protect the newborn's eyes from exposure to the bright lights. Closing the newborn's eyes before applying eyepatches helps shield the eyes from the light source and prevents potential damage to the eyes.
Correct Answer is A
Explanation
A. Postpartum hemorrhage: Effacement and dilation relate to the progress of labor, not postpartum hemorrhage. Postpartum hemorrhage is excessive bleeding that occurs after childbirth, typically within 24 hours, and can have various causes unrelated to cervical dilation.
B. Incompetent cervix: Incompetent cervix, also known as cervical insufficiency, refers to the premature and painless dilation of the cervix during the second trimester of pregnancy. It is not directly related to the dilation mentioned in the scenario. However, it is possible that the client may have misunderstood the timing of contractions, and the nurse should assess for other signs of cervical insufficiency.
C. Hyperemesis gravidarum: Hyperemesis gravidarum is severe nausea and vomiting during pregnancy, which can lead to dehydration and electrolyte imbalances. It is not directly related to cervical dilation or effacement.
D. Ectopic pregnancy: An ectopic pregnancy is a pregnancy that occurs outside the uterus, usually in the fallopian tube. Cervical dilation and effacement are not associated with ectopic pregnancies.
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