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 D
Explanation
Choice A rationale:
Increased pancreatic activity during pregnancy causing fat intolerance is not related to the cause of indigestion and heartburn. Pancreatic activity can change during pregnancy, but it does not directly impact indigestion and heartburn.
Choice B rationale:
Increased estrogen production causing more hydrochloric acid in the stomach is not the cause of indigestion and heartburn during pregnancy. While hormones can influence digestion, the mechanism for indigestion and heartburn lies elsewhere.
Choice C rationale:
Pressure from the growing uterus pushing up on the stomach and intestines is a contributing factor to indigestion and heartburn during pregnancy. However, it is not the primary cause. The main cause is related to the relaxation of the cardiac sphincter.
Choice D rationale:
Progesterone causes relaxation of the cardiac sphincter, which is a muscular valve that prevents stomach acid from flowing back into the esophagus. When this sphincter relaxes, it can lead to acid reflux and subsequent indigestion and heartburn during pregnancy. The nurse should educate the client about this hormonal effect to help manage these symptoms effectively.
Correct Answer is C
Explanation
The correct answer is choice C: "I will tip the nipple so air is present as my baby sucks.”
Choice A rationale:
The parent's statement in choice A, "I will keep my baby's head elevated while he is feeding,” indicates an understanding of proper bottle feeding techniques. Keeping the baby's head slightly elevated can help prevent choking and aspiration during feedings. This is a correct statement, and no further instruction is needed in this regard.
Choice B rationale:
The parent's statement in choice B, "I will allow my baby to burp several times during each feeding,” also demonstrates knowledge of appropriate bottle feeding practices. Burping the baby during and after feedings helps release swallowed air, reducing the likelihood of excessive gas and discomfort. This statement is correct, and no additional instruction is required.
Choice C rationale:
Choice C is the incorrect statement because tipping the nipple to introduce air while the baby sucks is not a recommended practice. In fact, it can lead to an increased intake of air, potentially causing gas, discomfort, and colic in the baby. Therefore, further instruction is needed to correct this misconception.
Choice D Rationale:
Choice D is not directly related to the need for further instruction in bottle feeding techniques and is not addressed in the explanation.
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