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.
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 .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse should inform the client that amniocentesis is a procedure that
determines if the baby has genetic or congenital disorders.
Choice B is not the best answer because amniocentesis is typically performed after 15 weeks of gestation.
Choice C is not the best answer because chorionic villus sampling (CVS) is a different procedure from amniocentesis.
Choice D is not the best answer because there is no age restriction for having an amniocentesis.
Correct Answer is A
Explanation
This is the most common symptom of placenta previa and can occur after 20 weeks of gestation.
Choice B is incorrect because a persistent headache is not a known symptom of placenta previa.
Choice C is incorrect because uterine hypertonicity is not a known symptom of placenta previa.
Choice D is incorrect because a firm, rigid abdomen is not a known symptom of placenta previa.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today