A nurse is caring for a client who is in labor.The nurse notes that the umbilical cord is protruding from the client’s vagina. Which of the following actions should the nurse take first?

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

Exert upward pressure on the presenting part

Answer and Explanation

The Correct Answer is D

The correct answer is choice d. Exert upward pressure on the presenting part.

Choice A rationale:

Administering a tocolytic medication can help reduce uterine contractions, but it is not the immediate priority in this emergency situation. The primary goal is to relieve pressure on the umbilical cord to restore blood flow to the fetus.

Choice B rationale:

Wrapping the cord in a sterile towel moistened with warm sterile normal saline is important to prevent the cord from drying out and to maintain its temperature. However, this action does not address the immediate need to relieve pressure on the cord.

Choice C rationale:

Applying oxygen via facemask to the client can help improve maternal oxygenation, which indirectly benefits the fetus. However, it does not directly address the immediate issue of relieving pressure on the umbilical cord.

Choice D rationale:

Exerting upward pressure on the presenting part is the most critical action to take first. This maneuver helps to relieve pressure on the umbilical cord, thereby restoring blood flow and oxygen to the fetus, which is essential in this emergency situation.

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Correct Answer is A

Explanation

Choice A rationale
Amniotic fluid embolism is a life-threatening emergency that can lead to cardiac and respiratory failure. Immediate initiation of cardiopulmonary resuscitation (CPR) is crucial to maintain circulation and oxygenation.
Choice B rationale
Ephedrine is not typically used in the management of amniotic fluid embolism. It is a vasopressor used to treat hypotension, but it is not the primary intervention in this situation.
Choice C rationale
Assessing for the presence of clonus is not relevant in this situation. Clonus is a neurological sign and is not directly related to amniotic fluid embolism.
Choice D rationale
Assisting the client to empty their bladder is not a priority action in this situation. The immediate concern is maintaining the client’s airway, breathing, and circulation.

A. Your provider will schedule a chorionic villus sampling to determine the sex of your baby. B. You cannot have an amniocentesis until you are at least 35 years of age. C. We can schedule the procedure for later today if you’d like. D. This procedure determines if your baby has genetic or congenital disorders.

Correct Answer is D

Explanation

Choice A rationale
Chorionic villus sampling (CVS) is a prenatal test that diagnoses chromosomal abnormalities such as Down syndrome, as well as a host of other genetic disorders. While it can determine the sex of the baby, it is not typically used for this purpose.

Choice B rationale
The statement that one cannot have an amniocentesis until they are at least 35 years of age is incorrect. While it is true that amniocentesis is often offered to women over the age of 35 due to an increased risk of chromosomal abnormalities, it can be performed on anyone at risk, regardless of age.
Choice C rationale
Scheduling the procedure for later in the day is not typically how amniocentesis is planned. It is a medical procedure that requires careful planning and preparation. It is usually performed between the 15th and 20th weeks of pregnancy.
Choice D rationale
This is the correct answer. Amniocentesis is a prenatal test that allows doctors to diagnose a range of genetic and chromosomal disorders. It involves taking a small sample of the amniotic fluid that surrounds the baby in the uterus for testing. The procedure can indeed determine if the baby has genetic or congenital disorders.

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A nurse is caring for a client who is in labor.The nurse notes that the umbilical cord is protruding from the client’s vagina. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is experiencing an amniotic fluid embolism during labor. What actions should the nurse take?

Correct Answer is A

Explanation

A nurse in a provider’s office is caring for a 20-year-old client who is at 12 weeks of gestation and requests an amniocentesis to determine the sex of the fetus. What responses should the nurse make?

Correct Answer is D

Explanation

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