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 C
Explanation
Choice A rationale:
Keeping the newborn dressed while receiving phototherapy is not recommended because the baby's skin needs to be exposed to the light to effectively treat hyperbilirubinemia. Direct exposure to light helps break down the excess bilirubin in the baby's blood, leading to its excretion.
Choice B rationale:
Applying lotion to the skin twice daily is contraindicated during phototherapy. Lotions and creams can block the light from reaching the skin and hinder the therapeutic effects of the phototherapy. The baby's skin should remain exposed to the light for optimal treatment.
Choice C rationale:
Maintaining an eye mask over the newborn's eyes is essential during phototherapy. The eyes are sensitive to light, and prolonged exposure to the phototherapy light can lead to eye damage. Using an eye mask protects the baby's eyes while allowing the rest of the body to receive the necessary light treatment.
Choice D rationale:
Maintaining the phototherapy during blood draws is crucial to ensure continuous treatment of hyperbilirubinemia. Interrupting the phototherapy during blood draws might result in the rebound of bilirubin levels, which can be harmful to the baby.
Correct Answer is A
Explanation
The correct answer is: A. Hemoglobin 12 g/dL.
Choice A reason:
Hemoglobin levels in newborns are expected to be significantly higher than in adults due to the physiological adaptation to life outside the womb. The normal range for a newborn’s hemoglobin is approximately 14 to 24 g/dL1234. A level of 12 g/dL is below the expected range and could indicate anemia or other underlying conditions that may require further investigation and intervention by the healthcare provider.
Choice B reason:
The glucose level in a newborn can vary, especially within the first few hours after birth. Normal blood glucose levels for a newborn 1 to 2 hours old can be as low as 25 mg/dL and can rise to adult levels (60-100 mg/dL) within the first few days5. A glucose level of 50 mg/dL in a 24-hour-old newborn falls within the acceptable range and would not typically require reporting to the provider unless accompanied by symptoms of hypoglycemia.
Choice C reason:
Bilirubin levels in newborns can be elevated due to the normal breakdown of fetal hemoglobin as the baby’s liver matures. Normal bilirubin levels for a newborn can range from 1.0 to 12.0 mg/dL6. A bilirubin level of 4 mg/dL is within the normal range for a 24-hour-old newborn and is not typically a cause for concern unless there are signs of jaundice or other symptoms.
Choice D reason:
The normal platelet count for a newborn ranges from 150,000 to 450,000/mm³7. A platelet count of 200,000/mm³ is well within the normal range for a newborn and would not need to be reported to the healthcare provider.
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