A nurse is performing a vaginal exam on a client who is in active labor. The nurse notes the umbilical cord protruding through the cervix. Which of the following actions should the nurse take?
Administer oxytocin to the client via intravenous infusion.
Apply oxygen at 2 L/min via nasal cannula.
Prepare for insertion of an intrauterine pressure catheter.
Assist the client into the knee-chest position.
The Correct Answer is D
Choice A rationale:
Administering oxytocin to the client via intravenous infusion is not appropriate when the nurse notes an umbilical cord protruding through the cervix. The priority is to relieve pressure on the cord to prevent fetal compromise, and administering oxytocin could worsen the situation.
Choice B rationale:
Applying oxygen at 2 L/min via nasal cannula is not the priority when an umbilical cord prolapse is detected. The focus should be on relieving pressure on the cord and changing the client's position to alleviate the compression.
Choice C rationale:
Preparing for insertion of an intrauterine pressure catheter is not appropriate when there is an umbilical cord prolapse. The immediate concern is the potential compromise of fetal blood flow, and addressing the cord prolapse takes precedence over any other interventions.
Choice D rationale:
Assisting the client into the knee-chest position is the correct action when an umbilical cord prolapse is observed during a vaginal exam. This position helps to alleviate pressure on the cord by moving the presenting part of the fetus off the cord and can prevent further fetal distress until more definitive interventions can be performed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Hypertonia (increased muscle tone) is not a manifestation of hypoglycemia in a newborn. Instead, hypotonia (decreased muscle tone) is more characteristic.
Choice B rationale:
This is the correct choice. Jitteriness is a common sign of hypoglycemia in a newborn. It may be accompanied by other symptoms like poor feeding, tremors, and irritability.
Choice C rationale:
Acrocyanosis (bluish discoloration of the hands and feet) is a normal finding in newborns and is not specifically associated with hypoglycemia.
Choice D rationale:
Generalized petechiae (small red or purple spots on the skin caused by bleeding under the skin) are not indicative of hypoglycemia but may be associated with other medical conditions.
Correct Answer is D
Explanation
Choice A rationale:
Periodic tingling of fingers is a common symptom during pregnancy and is often related to hormonal changes and increased fluid retention. While it can be uncomfortable, it is not necessarily an indication of a potential prenatal complication.
Choice B rationale:
Absence of clonus is not an abnormal finding during pregnancy. Clonus is a series of involuntary muscle contractions and relaxations and is generally not expected during a routine assessment.
Choice C rationale:
Leg cramps are a common complaint during pregnancy and are usually caused by changes in calcium and magnesium levels. While they can be uncomfortable, they are not typically considered an indication of a potential prenatal complication.
Choice D rationale:
Blurred vision can be an indication of preeclampsia, a serious condition that can occur during pregnancy. Preeclampsia is characterized by high blood pressure and damage to organs, often affecting the eyes, kidneys, and liver. It is crucial for the nurse to recognize this symptom and promptly inform the healthcare provider for further evaluation and management.
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