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: This is incorrect because preeclampsia is a condition characterized by hypertension, proteinuria, and edema that occurs after 20 weeks of gestation. It is not related to abruptio placentae, which is the premature separation of the placenta from the uterine wall. Preeclampsia does not cause petechiae or bleeding around the IV site, but it may cause headache, blurred vision, epigastric pain, or seizures.
Choice B: This is incorrect because anaphylactoid syndrome of pregnancy, also known as amniotic fluid embolism, is a rare and life-threatening complication that occurs when amniotic fluid enters the maternal circulation and triggers an allergic reaction. It is not related to abruptio placentae, but it may occur during labor, delivery, or shortly after birth. Anaphylactoid syndrome of pregnancy does not cause petechiae or bleeding around the IV site, but it may cause respiratory distress, hypotension, cardiac arrest, or disseminated intravascular coagulation.
Choice C: This is the correct answer because disseminated intravascular coagulation (DIC) is a condition in which the blood clotting system is activated abnormally, leading to excessive clot formation and consumption of clotting factors and platelets. This results in bleeding from various sites, such as the IV site, gums, nose, or vagina. DIC is a common complication of abruptio placentae, as the release of thromboplastin from the placenta triggers the clotting cascade. DIC can also cause organ failure, shock, or death if not treated promptly.
Choice D: This is incorrect because puerperal infection, also known as postpartum infection, is a bacterial infection that affects the uterus, vagina, bladder, or wound site after childbirth. It is not related to abruptio placentae, but it may occur due to prolonged labor, cesarean delivery, retained placenta, or poor hygiene. Puerperal infection does not cause petechiae or bleeding around the IV site, but it may cause fever, malaise, foul-smelling lochia, or pelvic pain.
Correct Answer is B
Explanation
Choice A) "Oh, don't worry about that. It's okay." is incorrect because this is not a helpful or informative response for a first-time father who is changing the diaper of his 1-day-old daughter. This response does not explain what the black, sticky stuff in the diaper is, why it is there, or how long it will last. It also does not address the father's concern or curiosity, and may make him feel dismissed or ignored. Therefore, this response is inadequate and inappropriate.
Choice B) "That's meconium, which is your baby's first stool. It's normal." is correct because this is a clear and accurate response for a first-time father who is changing the diaper of his 1-day-old daughter. This response explains what the black, sticky stuff in the diaper is, which is meconium. Meconium is a substance that consists of amniotic fluid, mucus, bile, and other waste products that accumulate in the baby's intestines before birth. It is usually passed within the first 24 to 48 hours after birth, and then replaced by transitional or regular stools. Meconium has a dark green or black color and a thick, sticky consistency. It does not have any odor or bacteria. It is normal and harmless for most babies, unless they inhale it during delivery, which can cause breathing problems or infection. Therefore, this response reassures and educates the father about his baby's condition.
Choice C) "That's transitional stool." is incorrect because this is not a true or complete response for a first-time father who is changing the diaper of his 1-day-old daughter. This response does not identify what the black, sticky stuff in the diaper is, which is meconium. Transitional stool is a type of stool that appears after meconium and before regular stools. It usually occurs between the second and fifth day after birth, and then changes to yellow or brown stools. Transitional stool has a greenish-brown color and a loose, seedy consistency. It may have some odor or bacteria. It indicates that the baby's digestive system is maturing and adapting to breast milk or formula. Therefore, this response confuses and misleads the father about his baby's condition.
Choice D) "That means your baby is bleeding internally." is incorrect because this is not a valid or appropriate response for a first-time father who is changing the diaper of his 1-day-old daughter. This response does not describe what the black, sticky stuff in the diaper is, which is meconium. Bleeding internally means that blood vessels are damaged or ruptured inside the body, causing blood loss and shock. This can be caused by various factors such as trauma, infection, clotting disorder, or medication. Bleeding internally can manifest as blood in the stool, urine, vomit, or saliva. However, it does not cause black, sticky stools like meconium. Moreover, this response scares and alarms the father without any evidence or reason. Therefore, this response is false and unethical.
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