A pregnant woman's amniotic membranes rupture and a prolapsed umbilical cord is found. What intervention would be the first priority?
Placing the woman in the knee-chest position.
Starting oxygen by facemask.
Preparing the woman for a vaginal birth.
Covering the cord in sterile gauze soaked in saline.
The Correct Answer is A
In the case of a prolapsed umbilical cord, the first priority intervention is to relieve pressure on the cord. Placing the woman in the knee-chest position or Trendelenburg position with the hips elevated is the best way to achieve this. This position helps to reduce the compression of the cord and improve fetal oxygenation.
Option B is incorrect because while oxygen may be necessary, relieving pressure on the cord is the priority.
Option C is incorrect because a vaginal birth should not proceed with a prolapsed umbilical cord, as it can cause cord compression and fetal distress.
Option D is incorrect because covering the cord in sterile gauze soaked in saline is not a priority intervention and may not be effective in relieving pressure on the cord.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Visual disturbances would require further action by the nurse as they can be a sign of worsening preeclampsia and a potential indication for immediate medical attention. The client's recent weight gain and elevated blood pressure are also concerning findings, but visual disturbances are a more urgent symptom. Frequent voiding in large amounts and 1+ pedal edema are common in pregnancy, while one headache in the past week may or may not be significant depending on the context.
Correct Answer is D
Explanation
The most common cause of excessive blood loss after childbirth is the failure of the uterine muscle to contract firmly, which is also known as uterine atony. If the uterus does not contract effectively after delivery, it cannot properly close off the blood vessels that were connected to the placenta, leading to heavy bleeding. Uterine atony can occur due to various factors, such as prolonged labor, multiple births, or the use of certain medications during labor.
Other causes of excessive blood loss after childbirth include retained placental fragments, vaginal or vulvar hematomas, or unrepaired lacerations of the vagina or cervix, but these are less common than uterine atony.
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