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 C
Explanation
Choice a) D5W intravenously is incorrect because this is not the preferred method of feeding for a hypoglycemic infant. D5W stands for dextrose 5% in water, which is a solution that contains glucose and water. It can be used to treat hypoglycemia by providing a source of energy and fluid to the infant. However, it has several disadvantages, such as requiring an invasive procedure, increasing the risk of infection, causing fluid overload or electrolyte imbalance, and stimulating insulin secretion, which can lead to rebound hypoglycemia. Therefore, D5W intravenously should be reserved for severe cases of hypoglycemia that do not respond to oral or enteral feeding.
Choice b) Formula via nasogastric tube is incorrect because this is not the first-line option of feeding for a hypoglycemic infant. Formula is an artificial substitute for breast milk that contains nutrients and calories to support the infant's growth and development. It can be given via nasogastric tube, which is a tube that passes through the nose and into the stomach, when the infant cannot suck or swallow effectively. However, formula has several disadvantages, such as being less digestible, less immunogenic, and less adaptable than breast milk, as well as increasing the risk of necrotizing enterocolitis, allergy, or infection. Therefore, formula via nasogastric tube should be used only when breast milk is unavailable or contraindicated.
Choice c) Breast milk is correct because this is the best and most recommended type of feeding for a hypoglycemic infant. Breast milk is the natural and optimal food for infants that contains all the nutrients and antibodies they need to grow and thrive. It can be given directly from the breast or expressed and fed by bottle or cup. Breast milk has several advantages, such as being easily digestible, enhancing immune function, promoting bonding, and adjusting to the infant's needs. Breast milk also contains lactose, which is a natural sugar that can raise the blood glucose level of the infant without causing a spike in insulin secretion. Therefore, breast milk should be offered to the hypoglycemic infant as soon as possible after birth and at regular intervals thereafter.
Choice d) Glucose water in a bottle is incorrect because this is not an appropriate type of feeding for a hypoglycemic infant. Glucose water is a solution that contains glucose and water. It can be given by bottle or cup to provide a quick source of energy to the infant. However, it has several disadvantages, such as providing no other nutrients or calories, interfering with breastfeeding, causing diarrhea or dehydration, and stimulating insulin secretion, which can lead to rebound hypoglycemia. Therefore, glucose water in a bottle should be avoided or used sparingly for mild cases of hypoglycemia that do not respond to breast milk.

Correct Answer is D
Explanation
Choice A) Report of absent breast pain is incorrect because this is not a finding that indicates that the medication was effective, but rather a finding that indicates that the client does not have mastitis or engorgement. Mastitis is an infection of the breast tissue that causes pain, swelling, redness, and fever. Engorgement is a condition where the breasts become overfilled with milk, causing pain, hardness, and leakage. Both conditions are common in postpartum women who are breastfeeding, but they are not related to methylergonovine or uterine bleeding. Therefore, this response is irrelevant and inaccurate.
Choice B) Increase in lochia is incorrect because this is not a finding that indicates that the medication was effective, but rather a finding that indicates that the medication was ineffective or that the client has a complication. Lochia is the vaginal discharge that consists of blood, mucus, and tissue from the uterus after childbirth. It usually lasts for about 4 to 6 weeks and gradually decreases in amount and color. Methylergonovine is a medication that helps to control uterine bleeding by improving the tone and contractions of the uterus. An increase in lochia may mean that methylergonovine did not work well or that the client has a problem such as retained placenta, infection, or subinvolution. Therefore, this response is opposite and inaccurate.
Choice C) Increase in blood pressure is incorrect because this is not a finding that indicates that the medication was effective, but rather a finding that indicates that the client has a side effect or a risk factor. Blood pressure is the force of blood against the walls of the arteries. It is measured by two numbers: systolic (the pressure when the heart beats) and diastolic (the pressure when the heart rests). The normal range for blood pressure is 120/80 mm Hg or lower. Methylergonovine is a medication that can cause vasoconstriction, which means narrowing of the blood vessels and increasing of the blood pressure. This can lead to complications such as hypertension, stroke, or heart attack. Therefore, this response is adverse and inaccurate.
Choice D) Fundus firm to palpation is correct because this is a finding that indicates that the medication was effective and that the client has a good outcome. The fundus is the upper part of the uterus that can be felt through the abdomen after childbirth. It should be firm, midline, and at or below the level of the navel. A firm fundus means that the uterus has contracted well and stopped bleeding. Methylergonovine is a medication that helps to achieve this by improving the tone and contractions of the uterus. Therefore, this response is positive and accurate.

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