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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This statement is correct, as these are the common complications of post-term infants, who are born after 42 weeks of gestation. Meconium aspiration can occur when the fetus passes meconium in utero and inhales it into the lungs, causing respiratory distress, inflammation, and infection. Hypoglycemia can occur due to the depletion of glycogen stores and the increased metabolic demands. Dry, cracked skin can occur due to the loss of vernix caseosa and the reduced amniotic fluid.
Choice B reason: This statement is incorrect, as these are the signs of neonatal hypocalcemia, which is a low level of calcium in the blood. Neonatal hypocalcemia can occur due to maternal diabetes, prematurity, or asphyxia, and can cause jitteriness, seizures, or tetany.
Choice C reason: This statement is incorrect, as these are the characteristics of preterm infants, who are born before 37 weeks of gestation. Excessive vernix caseosa covering the skin is a protective coating that prevents heat and water loss. Lethargy and RDS are signs of immaturity and underdevelopment of the central nervous system and the lungs.
Choice D reason: This statement is incorrect, as these are the features of infants with erythroblastosis fetalis, which is a hemolytic disease caused by the incompatibility of the Rh factor or the ABO blood group between the mother and the fetus. Golden yellow to green-stained skin and nails are due to the accumulation of bilirubin, which is a breakdown product of red blood cells. Absence of scalp hair and an increased amount of subcutaneous fat are due to the chronic hypoxia and edema.
Correct Answer is C
Explanation
Choice A reason: This statement is incorrect, as it describes the direct Coombs test, not the indirect Coombs test. The direct Coombs test is performed on the newborn's blood, and it detects the presence of maternal antibodies that have attached to the newborn's red blood cells. The direct Coombs test can help diagnose hemolytic disease of the newborn, which is a condition where the maternal antibodies destroy the newborn's red blood cells, causing anemia and jaundice.
Choice B reason: This statement is incorrect, as it is not the purpose of the indirect Coombs test, but rather a possible complication of hemolytic disease of the newborn. Kernicterus is a severe form of jaundice that occurs when the bilirubin level in the blood is very high, and it can cause brain damage, deafness, or death. Kernicterus can be prevented by treating the jaundice with phototherapy or exchange transfusion.
Choice C reason: This statement is correct, as it describes the indirect Coombs test, which is performed on the mother's blood, and it detects the presence of Rh-positive antibodies that have formed in response to the exposure to the Rh-positive blood of the newborn. The indirect Coombs test can help identify the risk of hemolytic disease of the newborn, and guide the administration of Rh immunoglobulin, which is a medication that prevents the formation of Rh-positive antibodies.
Choice D reason: This statement is incorrect, as it is not possible for the newborn to have Rh-negative antibodies, since the newborn has Rh-positive blood. Rh-negative antibodies are produced by Rh-negative individuals who have been exposed to Rh-positive blood, such as Rh-negative mothers who have Rh-positive newborns. Rh-negative antibodies can cross the placenta and attack the Rh-positive red blood cells of the newborn, causing hemolytic disease of the newborn.
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