A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?

Insert a gloved hand into the vagina to relieve pressure on the cord.

Cover the cord with a sterile, moist saline dressing.

Place the client in knee-chest position.

Prepare the client for an immediate birth.

Answer and Explanation

The Correct Answer is A

Choice A reason: This action is the first and most important intervention that the nurse should perform, as it can prevent or reduce the compression of the umbilical cord, which can cause fetal hypoxia, bradycardia, or death. The nurse should insert a gloved hand into the vagina and gently push the presenting part away from the cord, and maintain this position until the delivery.

Choice B reason: This action is not the first intervention that the nurse should perform, as it does not address the cause of the cord prolapse, which is the displacement of the cord below the presenting part. However, this action is helpful to prevent the drying and infection of the cord, and should be done after the first intervention.

Choice C reason: This action is not the first intervention that the nurse should perform, as it may not be effective or feasible depending on the stage of labor and the client's condition. However, this action is beneficial to reduce the pressure of the presenting part on the cord, and should be done after the first intervention.

Choice D reason: This action is not the first intervention that the nurse should perform, as it does not provide immediate relief or protection to the fetus. However, this action is necessary to expedite the delivery and prevent further complications, and should be done after the first intervention.

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Correct Answer is B

Explanation

Choice A reason: Reinforcing postpartum and newborn care discharge teaching is not a priority action by the nurse, as it is not directly related to the client's emotional state or safety. Reinforcing postpartum and newborn care discharge teaching is an important intervention that can help the client to manage her physical recovery and her infant's needs, but it is not sufficient to address the client's symptoms of postpartum depression, which is a mood disorder that can affect the client's mental health and well-being.

Choice B reason: Asking the client if she has considered harming her newborn is a priority action by the nurse, as it is essential to assess the client's risk of infanticide, which is the intentional killing of an infant by the mother. Asking the client if she has considered harming her newborn is a sensitive and difficult question, but it is necessary to ensure the safety of the infant and the mother, and to provide appropriate interventions and referrals. The nurse should ask the question in a nonjudgmental and supportive manner, and validate the client's feelings and concerns.

Choice C reason: Assisting the family to identify prior use of positive coping skills in family crises is not a priority action by the nurse, as it is not directly related to the client's emotional state or safety. Assisting the family to identify prior use of positive coping skills in family crises is a helpful intervention that can enhance the client's resilience and self-efficacy, but it is not sufficient to address the client's symptoms of postpartum depression, which is a mood disorder that can affect the client's mental health and well-being.

Choice D reason: Anticipating a prescription by the provider for an antidepressant is not a priority action by the nurse, as it is not directly related to the client's emotional state or safety. Anticipating a prescription by the provider for an antidepressant is a possible intervention that can improve the client's mood and functioning, but it is not the only or the first option to address the client's symptoms of postpartum depression, which is a mood disorder that can affect the client's mental health and well-being. The nurse should collaborate with the provider and the client to determine the best treatment plan, which may include psychotherapy, social support, or alternative therapies.

A. Molar pregnancy B. Previous history of hyperemesis gravidarum C. Oligohydramnios D. Multiple fetal gestation

Correct Answer is C

Explanation

Choice A reason: Molar pregnancy is a risk factor for hyperemesis gravidarum, as it is a gestational trophoblastic disease that causes an abnormal growth of the placenta and the production of high levels of human chorionic gonadotropin (hCG), which is a hormone that stimulates nausea and vomiting. Molar pregnancy can cause severe and persistent hyperemesis gravidarum, as well as vaginal bleeding, uterine enlargement, and preeclampsia.

Choice B reason: Previous history of hyperemesis gravidarum is a risk factor for hyperemesis gravidarum, as it suggests a genetic or physiological predisposition to the condition. Hyperemesis gravidarum is a severe form of nausea and vomiting that occurs in pregnancy, and it can cause dehydration, electrolyte imbalance, weight loss, and malnutrition. Hyperemesis gravidarum can recur in subsequent pregnancies, especially if the mother has the same partner, the same sex of the fetus, or a short interval between pregnancies.

Choice C reason: Oligohydramnios is not a risk factor for hyperemesis gravidarum, as it is a low level of amniotic fluid that surrounds the fetus. Oligohydramnios is not related to hyperemesis gravidarum, and it is not a cause or a consequence of it. Oligohydramnios can affect the fetal development and the delivery, as it can cause fetal growth restriction, cord compression, or meconium aspiration.

Choice D reason: Multiple fetal gestation is a risk factor for hyperemesis gravidarum, as it is a condition where the mother is carrying more than one fetus. Multiple fetal gestation can cause higher levels of hCG, estrogen, and progesterone, which are hormones that stimulate nausea and vomiting. Multiple fetal gestation can cause more severe and prolonged hyperemesis gravidarum, as well as preterm labor, anemia, and preeclampsia.

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A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?

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Naxlex Comprehensive Predictor Exams

A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling very sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?

Correct Answer is B

Explanation

A nurse in a clinic is assessing a client who is at 8 weeks of gestation and has been diagnosed with hyperemesis gravidarum. Which of the following is not a risk factor for hyperemesis gravidarum?

Correct Answer is C

Explanation

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