A woman is in active labor. On spontaneous rupture of her membranes, the nurse caring for this woman notices variable deceleration patterns during evaluation of the monitor tracing. When preparing to perform a vaginal examination, the nurse observes a small section of the umbilical cord protruding from the vagina. What should the nurse do next?
Wrap the cord loosely with a sterile towel saturated with warm normal saline.
Place a sterile gloved hand into the vagina and hold the presenting part off the cord while calling for assistance.
Increase the IV drip rate.
Administer oxygen to the woman via mask at 8 to 10 L/minute.
The Correct Answer is B
Choice A) Wrap the cord loosely with a sterile towel saturated with warm normal saline: This is not an appropriate action because it does not relieve the compression of the cord, which can cause fetal hypoxia and acidosis. The cord should be kept moist, but not wrapped around anything.
Choice B) Place a sterile gloved hand into the vagina and hold the presenting part off the cord while calling for assistance: This is the correct action because it prevents further descent of the fetus and reduces the pressure on the cord, which can improve fetal oxygenation and blood flow. The nurse should also elevate the woman's hips and place her in a knee-chest or Trendelenburg position to reduce gravity. The nurse should call for immediate assistance and prepare for an emergency cesarean section.
Choice C) Increase the IV drip rate: This is not an appropriate action because it does not address the cause of the variable decelerations, which is cord compression. Increasing the IV fluid may cause fluid overload and worsen maternal and fetal outcomes.
Choice D) Administer oxygen to the woman via mask at 8 to 10 L/minute: This is not an appropriate action because it does not relieve the cord compression, which is the main threat to fetal well-being. Oxygen administration may be helpful in some cases of fetal distress, but it is not sufficient in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: This is incorrect because acetylsalicylic acid (ASA), also known as aspirin, is not a cure for preeclampsia, but a preventive measure. ASA may reduce the risk of preeclampsia in some high-risk women by inhibiting platelet aggregation and improving blood flow to the placenta. However, ASA is not recommended for all pregnant women, as it may have adverse effects on the mother and the fetus, such as bleeding, premature closure of the ductus arteriosus, or fetal growth restriction.
Choice B: This is the correct answer because delivery of the fetus is the only definitive treatment for preeclampsia, as it eliminates the source of the placental factors that cause the condition. Preeclampsia is a multisystem disorder characterized by hypertension, proteinuria, and edema that occurs after 20 weeks of gestation. It is caused by abnormal placentation and endothelial dysfunction that lead to vasoconstriction, inflammation, and coagulation.
Delivery of the fetus and the placenta resolves these abnormalities and restores normal maternal physiology.
Choice C: This is incorrect because antihypertensive medications are not a cure for preeclampsia, but a symptomatic management. Antihypertensive medications may lower the blood pressure and reduce the risk of maternal complications, such as stroke, seizure, or organ damage. However, antihypertensive medications do not address the underlying cause of preeclampsia and do not improve fetal outcomes. Moreover, some antihypertensive medications are contraindicated in pregnancy due to their teratogenic effects.
Choice D: This is incorrect because magnesium sulfate is not a cure for preeclampsia, but a prophylaxis for eclampsia. Eclampsia is a severe complication of preeclampsia that involves seizures and coma. Magnesium sulfate is an anticonvulsant that prevents or treats eclamptic seizures by stabilizing neuronal membranes and reducing cerebral edema. However, magnesium sulfate does not lower blood pressure or improve renal function in preeclamptic women. It also has side effects such as nausea, flushing, headache, or respiratory depression.
Correct Answer is B
Explanation
Choice A) Increased urinary output: This is not a sign of sepsis in newborns. In fact, sepsis can cause reduced urinary output due to poor blood flow to the kidneys and dehydration.
Choice B) Hypothermia: This is a sign of sepsis in newborns. Sepsis can cause changes in temperature, often fever, but sometimes low temperature. Hypothermia can indicate a severe infection that affects the body's ability to regulate its temperature.
Choice C) Wakefulness: This is not a sign of sepsis in newborns. Sepsis can cause reduced activity and lethargy due to inflammation and organ dysfunction.
Choice D) Interest in feeding: This is not a sign of sepsis in newborns. Sepsis can cause reduced sucking and difficulty feeding due to poor appetite, nausea, vomiting, and abdominal distension.
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