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 D
Explanation
Choice A: This is incorrect because both physiological and nonphysiological jaundice result from breakdown of erythrocytes. Jaundice is caused by the accumulation of bilirubin, a yellow pigment that is produced when red blood cells are destroyed. However, the rate and extent of hemolysis differ between the two types of jaundice.
Choice B: This is incorrect because kernicterus is a rare and serious complication of jaundice, not a usual outcome. Kernicterus occurs when bilirubin levels are very high and the pigment deposits in the brain, causing neurological damage. It can affect both physiological and nonphysiological jaundice, but it is more likely to occur in nonphysiological jaundice due to higher bilirubin levels and underlying conditions.
Choice C: This is incorrect because both physiological and nonphysiological jaundice begin at the head and progress down the body. This is because bilirubin accumulates in areas with high fat content, such as the skin, eyes, and brain. The distribution of jaundice depends on the level of bilirubin in the blood, not on the type of jaundice.
Choice D: This is the correct answer because nonphysiological jaundice appears in the first 24 hours of life, whereas physiological jaundice appears after the first 24 hours of life. Nonphysiological jaundice is caused by factors that increase hemolysis or impair bilirubin metabolism or excretion, such as blood group incompatibility, infection, liver disease, or enzyme deficiency. Physiological jaundice is caused by normal adaptation processes that occur after birth, such as increased red blood cell turnover, immature liver function, and delayed intestinal flora colonization.
Correct Answer is C
Explanation
Choice A) Missed abortion: This is not the correct obstetric complication for methotrexate treatment. A missed abortion is a type of miscarriage in which the fetus has died but the products of conception are still retained in the uterus. Methotrexate is not used for this condition, as it can cause toxicity and bleeding. The usual treatment options for a missed abortion are expectant management, medical induction, or surgical evacuation.
Choice B) Abruptio placentae: This is not the correct obstetric complication for methotrexate treatment. Abruptio placentae is a condition in which the placenta separates from the uterine wall before delivery, causing bleeding and fetal distress. Methotrexate is not used for this condition, as it can worsen the bleeding and harm the fetus. The usual treatment options for abruptio placentae depend on the severity of the condition and the gestational age, but they may include fluid resuscitation, blood transfusion, tocolysis, or emergency delivery.
Choice C) Unruptured ectopic pregnancy: This is the correct obstetric complication for methotrexate treatment. An ectopic pregnancy is a pregnancy that implants outside of the uterine cavity, usually in the fallopian tube. An unruptured ectopic pregnancy is one that has not caused any bleeding or rupture of the tube. Methotrexate is used for this condition, as it can dissolve the pregnancy tissue and prevent further growth and complications.
Methotrexate is given as an injection and works by inhibiting folic acid metabolism, which is essential for cell division.
Methotrexate is only suitable for patients who have stable vital signs, low levels of human chorionic gonadotropin (hCG), and no fetal heartbeat or cardiac activity detected by ultrasound.
Choice D) Complete hydatidiform mole: This is not the correct obstetric complication for methotrexate treatment. A complete hydatidiform mole is a type of gestational trophoblastic disease in which there is an abnormal proliferation of placental tissue without any fetal development. Methotrexate is not used for this condition, as it can cause resistance and recurrence. The usual treatment option for a complete hydatidiform mole is suction curettage, which removes the molar tissue from the uterus.
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