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:
Leaving the diaphragm in place for 4 hours following intercourse is incorrect. The diaphragm should be left in place for at least 6 hours after intercourse to ensure effectiveness in preventing pregnancy.
Choice B rationale:
Removing the diaphragm by catching the rim below the dome with the forefinger is incorrect. The diaphragm should be removed by hooking the finger behind the rim to avoid damaging the dome and ensure proper removal.
Choice C rationale:
Placing a thin layer of mineral oil on the diaphragm once per week is incorrect. Mineral oil can weaken latex diaphragms, reducing their effectiveness. Water-based lubricants are recommended for use with diaphragms.
Choice D rationale:
Placing 2 teaspoons of spermicide on the inside of the diaphragm before insertion is the correct technique. Spermicide helps to immobilize and kill sperm, enhancing the contraceptive effect of the diaphragm.
Correct Answer is C
Explanation
Choice A rationale:
This statement indicates that the client understands the potential side effects of oral contraception and the importance of reporting them promptly to their healthcare provider. Chest pain, shortness of breath, or leg pain can be indicative of serious complications, such as blood clots, which can occur with oral contraceptive use.
Choice B rationale:
This statement demonstrates the client's understanding of what to do if they miss three pills. Using an alternative form of birth control is a responsible action to prevent unintended pregnancies, as missing multiple pills can decrease contraceptive effectiveness.
Choice C rationale:
This statement reveals a misunderstanding of the appropriate action to take if the client misses three pills. Instead of doubling up, the client should be instructed to take the missed pill as soon as they remember and continue taking the pills as usual. Doubling up can increase the risk of side effects and won't necessarily prevent pregnancy.
Choice D rationale:
This statement indicates that the client comprehends the need for follow-up appointments while on oral contraception. Regular follow-ups are essential to monitor the client's health, address any concerns, and ensure the effectiveness of the chosen contraceptive method.
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