During a vaginal delivery, the first thing a nurse must ensure when the head comes out is that the midwife or doctor checks that
The cord is still pulsating.
The cord is intact.
No part of the cord is encircling the baby's neck.
The cord is still attached to the placenta.
The Correct Answer is C
Choice A reason:
The cord is still pulsating. This is not the first thing a nurse must ensure when the head comes out because the cord normally pulsates until the placenta is delivered. The pulsation indicates that the cord is still functioning and transferring blood and oxygen between the baby and the placenta. However, this does not mean that the cord is free from any complications that could endanger the baby's life, such as a nuchal cord (a cord wrapped around the neck) or a prolapsed cord (a cord that slips out before the baby). • Choice B reason:
The cord is intact. This is not the first thing a nurse must ensure when the head comes out because the cord is usually intact until it is clamped and cut after the delivery of the baby. The cord can be ruptured by excessive traction or twisting, which can cause bleeding and shock in the baby. However, this is a rare occurrence and does not pose an immediate threat to the baby's life as long as the cord is still attached to the placenta. • Choice C reason:
No part of the cord is encircling the baby's neck. This is the correct answer because a nuchal cord can cause compression of the cord and reduce blood flow and oxygen to the baby, leading to fetal distress, hypoxia, and brain damage. A nuchal cord occurs in about 10 to 30 percent of deliveries and can be detected by feeling for a loop of cord around the neck as the head emerges. If a nuchal cord is present, it should be gently slipped over the head or clamped and cut before delivery of the shoulders. • Choice D reason:
The cord is still attached to the placenta. This is not the first thing a nurse must ensure when the head comes out because the cord is always attached to the placenta until it separates from the uterine wall and is expelled after the delivery of the baby. The placenta provides nourishment and oxygen to the baby through the cord. However, this does not mean that the cord is free from any complications that could endanger the baby's life, such as a nuchal cord or a prolapsed cord.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Assisting the client on a bedpan to urinate is important for assessing urinary output and preventing bladder distension. However, in this situation, the priority is to assess and manage postpartum hemorrhage, which is indicated by the excessive bleeding.
Choice B reason:
Increasing the client's fluid intake is generally a good measure for promoting hydration and maintaining blood volume. However, it is not the priority in this scenario of excessive postpartum bleeding.
Choice C reason:
Palpating the client's uterine fundus is the priority nursing intervention at this time. The excessive bleeding indicated by saturating two perineal pads in a 30-minute period suggests postpartum hemorrhage, which can result from uterine atony (failure of the uterus to contract adequately after childbirth). Palpating the fundus allows the nurse to assess if the uterus is firm or boggy, and if it is not contracting properly, immediate interventions can be initiated to control the bleeding.
Choice D reason:
Preparing to administer oxytocic medication (such as oxytocin) can help stimulate uterine contractions and prevent or manage postpartum hemorrhage. However, the priority is to first assess the uterine fundus and confirm the cause of the excessive bleeding before administering any medication.
Correct Answer is A
Explanation
Choice A reason:
The nurse's priority in this situation is the client's blood pressure of 80/56 mm Hg. Opioid epidural analgesia can cause a drop in blood pressure, known as hypotension. Hypotension can be a significant concern during labor, as it may reduce blood flow to the placenta and compromise the baby's well-being. Therefore, it is crucial for the nurse to address this finding promptly to prevent any adverse effects on both the mother and the baby. The nurse may need to administer intravenous fluids, adjust the dosage of the opioid medication, or take other appropriate actions to raise the blood pressure to a safer level.
Choice B reason:
While profuse itching (choice B) can be a common side effect of opioids, it is not the nurse's priority in this situation. Itching, also known as pruritus, can be managed with antihistamines or other supportive measures, but it is not an immediate threat to the client's well-being.
Choice C reason:
The client reporting weakness of the lower extremities (choice C) is an expected side effect of epidural analgesia. Epidurals can cause temporary paralysis or weakness in the lower body due to the local anesthetic's effects on the nerves. While it's essential to monitor and support the client during this time, it is not the priority over the potentially dangerous drop in blood pressure.
Choice D reason:
A temperature of 38.2°C (100.8 F) (choice D) may indicate a fever, but it is not the nurse's priority in this specific situation of opioid epidural analgesia during labor. Fever during labor could have various causes, and the nurse should investigate and manage it appropriately. However, addressing the client's blood pressure takes precedence, as hypotension can have immediate and significant consequences.
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