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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Correct answer: C. Poor feeding
Newborns exposed to methadone in utero are at risk for neonatal abstinence syndrome (NAS), which can manifest with:
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Poor feeding due to uncoordinated suck and swallow reflexes, irritability, and gastrointestinal symptoms.
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High-pitched cry, not weak—so option B is incorrect.
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Exaggerated Moro reflex, not absent—so option A is incorrect.
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Tachypnea (rapid breathing), often >60/min—so a respiratory rate of 30/min is abnormally low and not expected in this context, making option D incorrect.
Correct Answer is ["A","C","D","F","G","H"]
Explanation
Choice A rationale: A positive Coombs test indicates that the newborn has antibodies against his own red blood cells, which can lead to hemolytic disease of the newborn. This condition can cause severe anemia and jaundice, which can lead to complications such as kernicterus if not treated promptly.
Choice B rationale: The newborn’s glucose level is within the normal range (40 to 60 mg/dL), so this finding does not require immediate follow-up.
Choice C rationale: The yellow color of the sclera indicates jaundice, which can be a sign of hyperbilirubinemia. This condition can lead to complications such as kernicterus if bilirubin levels become too high.
Choice D rationale: The absence of meconium stool in a 36-hour-old newborn is unusual, as most newborns pass meconium within the first 24 to 48 hours after birth. This could indicate a problem such as meconium ileus or Hirschsprung disease, which would require further evaluation.
Choice E rationale: The head assessment finding of caput succedaneum is a common and typically harmless condition in newborns caused by pressure on the head during delivery. It does not require immediate follow-up.
Choice F rationale: The newborn’s heart rate is slightly elevated (normal range for a newborn is 120-160 beats per minute). This could be a response to factors such as fever, pain, or distress, and should be reported to the provider.
Choice G rationale: The newborn’s respiratory rate is also elevated (normal range for a newborn is 30-60 breaths per minute). This could be a sign of respiratory distress and should be reported to the provider.
Choice H rationale: Dry mucous membranes can be a sign of dehydration, which can occur if the newborn is not feeding well or is losing too much fluid, for example, through excessive sweating due to fever. This should be reported to the provider.
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