A nurse is caring for a client who is in labor.
Select the 5 actions the nurse should take.
Exert upward pressure on the presenting part.
Place the client in a Trendelenburg position.
Administer oxygen at 10 L/min via nonrebreather face mask.
Attempt to push the umbilical cord back into the cervix.
Have the charge nurse notify the provider.
Increase the flow rate of the maintenance IV fluid.
Correct Answer : A,B,C,E,F
A. Exert upward pressure on the presenting part. If there are signs of cord prolapse or pressure on the umbilical cord, exerting upward pressure on the presenting part can relieve compression. This action helps maintain blood flow and oxygen supply to the fetus.
B. Place the client in a Trendelenburg position. Positioning the client with the pelvis elevated higher than the head can reduce pressure on the umbilical cord if prolapse is suspected or confirmed. This promotes fetal circulation and decreases the risk of hypoxia.
C. Administer oxygen at 10 L/min via nonrebreather face mask. Administering high-flow oxygen increases maternal oxygenation, which in turn improves oxygen delivery to the fetus. This is a priority intervention to ensure fetal well-being during labor.
D. Attempt to push the umbilical cord back into the cervix. This is incorrect because pushing the cord back into the cervix is contraindicated due to the risk of damaging the cord or introducing infection. Other measures, such as repositioning and elevating the presenting part, should be prioritized instead.
E. Have the charge nurse notify the provider. Timely communication with the provider is critical when complications arise during labor, such as suspected umbilical cord prolapse. The provider may need to intervene urgently, possibly requiring an emergency cesarean section.
F. Increase the flow rate of the maintenance IV fluid. Increasing the IV fluid rate helps improve maternal circulation and blood flow to the uterus and placenta, ensuring the fetus receives adequate oxygen and nutrients. This is a supportive measure during labor when complications arise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Protect the IV bag from exposure to light: Nitroprusside is light-sensitive and degrades when exposed to light, reducing its potency and effectiveness. It must be protected with an opaque covering.
B. Keep calcium gluconate at the client’s bedside: Incorrect. Calcium gluconate is used to treat hyperkalemia or calcium imbalances, not for nitroprusside administration.
C. Attach an inline filter to the IV tubing: Incorrect. An inline filter is not typically required for nitroprusside.
D. Monitor blood pressure every 2 hr: Incorrect. Continuous or frequent monitoring (every 5-15 minutes) is necessary due to the rapid effects of nitroprusside on blood pressure.
Correct Answer is B
Explanation
A. Levothyroxine is usually administered in the morning and is prescribed correctly here.
B. The prescribed dose of Digoxin 250 mcg is unusually high for a daily dose. Typically, digoxin is prescribed in lower doses, and the nurse should clarify this prescription with the provider to ensure it is correct.
C. Ceftriaxone is correctly prescribed as an IV antibiotic with a standard interval.
D. Acetaminophen is correctly prescribed as a dosage of 650 mg every 6 hours.
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