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
Magnesium sulfate is used to prevent seizures in women with preeclampsia.
However, taking too much magnesium can be life-threatening to both mother and child.
In women, one of the most common symptoms of magnesium toxicity is muscle weakness12.
Choice B is not an answer because increased fetal movement is not a symptom of magnesium toxicity.
Choice C is not an answer because increased respiratory rate is not a symptom of magnesium toxicity.
Choice D is not an answer because increased urinary output is not a symptom of magnesium toxicity.
Correct Answer is B
Explanation
The correct answer is. Administering broad-spectrum antibiotics.
Cleansing the site with povidone-iodine is not recommended because it can be irritating and potentially harmful to the exposed neural tissue.
Monitoring the rectal temperature every 4 hours is not appropriate as it can increase the risk of infection and trauma to the site. Axillary temperature monitoring is preferred.
Preparing for surgical closure after 72 hours is incorrect. Surgical closure is typically performed within the first 24 to 48 hours to prevent infection and further damage to the neural tissue.
Administering broad-spectrum antibiotics is crucial to prevent infection, especially since the cerebrospinal fluid is leaking, which increases the risk of meningitis and other infections.
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