A nurse is caring for a client who is in the active phase of labor. The nurse palpates the umbilical cord during a vaginal examination. Which of the following actions should the nurse take?
Decrease the rate of the IV infusion.
Place the client in a knee-chest position.
Instruct the client to push with the next contraction.
Replace the umbilical cord into the cervix
The Correct Answer is B
A. Decreasing IV infusion rate does not relieve umbilical cord prolapse.
B. Placing the client in a knee-chest position helps relieve pressure on the prolapsed umbilical cord, improving fetal oxygenation until delivery.
C. Instructing the client to push can worsen cord compression and is contraindicated.
D. The nurse should not attempt to replace the umbilical cord into the cervix; this is a sterile procedure typically performed by the provider.
Nursing Test Bank
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Related Questions
Correct Answer is A
Explanation
A. Spending individual time with the preschooler helps reduce feelings of jealousy and promotes security during the transition.
B. Moving the child too close to the arrival of the new baby can increase stress; it’s better to make such changes well in advance.
C. The preschooler might feel excluded or jealous if they see the parent holding the baby first; it is better to prepare them beforehand.
D. Including the preschooler in prenatal visits can help them feel involved and less anxious about the new sibling.
Correct Answer is D
Explanation
A. The electronic monitoring band should remain on the newborn at all times to ensure security.
B. While visitor limitations may be advised during outbreaks or pandemics, this is not a standard newborn security measure.
C. Sending the newborn to the nursery unsupervised increases the risk of abduction and is not recommended.
D. Parents should be encouraged to verify staff identification to enhance newborn security and safety.
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