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 C
Explanation
A nurse caring for a client who has hyperemesis gravidarum should anticipate urine ketones test.
Hyperemesis gravidarum is severe nausea and vomiting during pregnancy that results in dehydration, weight loss, and ketosis.
Urine ketones test is done to check for ketosis which is a sign of starvation 2.
Choice A, Rapid plasma reagin, is not an answer because it is a blood test used to screen for syphilis.
Choice B, Prothrombin time, is not an answer because it is a blood test used to measure how long it takes for blood to clot.
Choice D, Urine culture, is not an answer because it is a test used to detect and identify bacteria or yeast that may be causing a urinary tract infection.
Correct Answer is D
Explanation
Fortified soy milk is a good source of vitamin B2 for vegans.
Choice A is not the answer because brown rice was not mentioned in the search results as a source of vitamin B2.
Choice B is not the answer because raw carrots were not mentioned in the search results as a source of vitamin B2.
Choice C is not the answer because fresh citrus fruits were not mentioned in the search results as a source of vitamin B2.
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