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 C
Explanation
A. The risk of overdose is minimized by the device's programming.
B. The medication is limited based on a preset dose and frequency.
C. PCA pumps deliver a controlled dose of medication, preventing overdose by limiting the amount dispensed.
D. Only the client should press the button to ensure safety.
Correct Answer is B
Explanation
A. Weight gain is a common side effect but does not require immediate reporting unless significant.
B. Shuffling gait is a sign of extrapyramidal symptoms (EPS), which can lead to tardive dyskinesia and requires prompt evaluation.
C. Dry mouth is a common side effect and can be managed with increased fluid intake or sugar-free candy.
D. Sedation is a common side effect but is not typically a reason to contact the provider unless it significantly impacts daily activities.
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