A nurse is caring for a client who reports spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and notices that the umbilical cord is protruding.
After calling for assistance and notifying the provider, which of the following actions should the nurse take next?

Cover the umbilical cord with a sterile saline saturated towel.

Perform a vaginal examination by applying upward pressure on the presenting part.

Administer oxygen via non-rebreather mask at 8 L/min.

Initiate an infusion of IV ﬂuids for the client.

Answer and Explanation

The Correct Answer is B

If a prolapsed cord is identiﬁed, the nurse should perform a vaginal examination and ensure the presenting part is pushed upwards to relieve pressure on the cord.

Choice A) is not correct because while it is important to cover the cord with a sterile saline saturated towel if it has prolapsed externally 1, it is not the next action after calling for assistance and notifying the provider.

Choice C) is not correct because administering oxygen via non-rebreather mask at 8 L/min is not mentioned as an immediate intervention for a prolapsed cord .

Choice D) is not correct because initiating an infusion of IV ﬂuids for the client is not mentioned as an immediate intervention for a prolapsed cord .

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Correct Answer is A

Explanation

A. The nurse should monitor for chorioamnionitis, which is an infection of the amniotic sac and ﬂuid.

The other choices are not potential complications of gonorrhea:

B. Vaginal laceration during birth is not a complication of gonorrhea.

C. Oligohydramnios is not a complication of gonorrhea.

D. Excessive bleeding after birth is not a complication of gonorrhea.

A. Inactivated inﬂuenza. B. Human papillomavirus. C. Varicella. D. Measles, mumps, and rubella. E. Diphtheria-acellular pertussis.

Correct Answer is ["A","E"]

Explanation

The nurse should plan to immunize the client with the inactivated inﬂuenza vaccine (A) and the diphtheria-acellular pertussis vaccine (E).

The Centers for Disease Control and Prevention (CDC) recommends that pregnant women get two vaccines during every pregnancy: the inactivated ﬂu vaccine and the Tdap vaccine.

The other vaccines listed are not recommended during pregnancy:

The human papillomavirus vaccine is not recommended during pregnancy.
The varicella vaccine is not recommended during pregnancy.
The measles, mumps, and rubella vaccine is not recommended during pregnancy.

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A nurse is caring for a client who reports spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and notices that the umbilical cord is protruding. After calling for assistance and notifying the provider, which of the following actions should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in active labor and has gonorrhea. For which of the following potential complications of gonorrhea should the nurse monitor?

Correct Answer is A

Explanation

A nurse is caring for a client who is at 30 weeks of gestation. The nurse should plan to immunize the client with which of the following vaccines? (Select all that apply.)

Correct Answer is ["A","E"]

Explanation

A nurse is providing teaching to a postpartum client who has a prescription for a rubella immunization. Which of the following client statements indicates understanding of the teaching?

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A nurse is caring for a client who is at 32 weeks of gestation and has gestational diabetes mellitus. Which of the following findings should the nurse report to the provider?

A nurse is assisting the provider to administer a dinoprostone insert to induce labor for a client. Which of the following actions should the nurse take?

A nurse is preparing to perform a fundal massage for a postpartum client who is experiencing uterine atony. In which order should the nurse plan to perform the following actions?

A nurse is caring for a client who is in the latent phase of the first stage of labor and is in pain. Which of the following nursing interventions are appropriate to reduce pain? (Select all that apply.)

A nurse is caring for a newborn. Which of the following assessment findings should indicate to the nurse that suctioning of the nasopharynx is needed?

A nurse is caring for a client who reports spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and notices that the umbilical cord is protruding.
After calling for assistance and notifying the provider, which of the following actions should the nurse take next?