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 {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"C"},"E":{"answers":"C"}}
Explanation
• Regurgitation: This could be a sign of potential worsening condition as it might indicate gastrointestinal issues, which can be a symptom of Neonatal Abstinence Syndrome (NAS).
• Transient strabismus: This is unrelated to the diagnosis. Strabismus is common in newborns and usually resolves on its own within the first few months of life.
• Mottling: This could be a sign of potential worsening condition. Mottling (a lacy pattern of dilated blood vessels under the skin) can be a sign of distress in a newborn.
• Respiratory rate 70/min: This could be a sign of potential worsening condition. A respiratory rate of 70/min is higher than the normal range (30-60 breaths per minute) for a newborn, indicating possible respiratory distress.
• Continuous high-pitched cry: This could be a sign of potential worsening condition. A high-pitched cry is a common symptom of NAS.
• Loose stools: This could be a sign of potential worsening condition. Loose stools can be a symptom of NAS.
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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