“A nurse is caring for a patient who reports spontaneous rupture of membranes.
The nurse observes fetal bradycardia on the FHR tracing and notices that the umbilical cord is protruding.
After calling for assistance and notifying the provider, which of the following actions should the nurse take next?”
“Initiate an infusion of IV fluids for the patient.”.
“Administer Oxygen via nonrebreather mask at 8L/min.”.
“Perform a vaginal examination by applying upward pressure on the presenting part.”.
“Cover the umbilical cord with a sterile saline saturated towel.”. .
The Correct Answer is C
Choice A rationale
While initiating an infusion of IV fluids for the patient is important, it is not the immediate next step after noticing a protruding umbilical cord.
Choice B rationale
Administering oxygen via a nonrebreather mask at 8L/min is a later step in the management of umbilical cord prolapse.
Choice C rationale
The immediate next step after noticing a protruding umbilical cord is to perform a vaginal examination and apply upward pressure on the presenting part to relieve cord compression.
Choice D rationale
Covering the umbilical cord with a sterile saline-saturated towel is a later step in the management of umbilical cord prolapse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
The Plastibell is not removed 4 hours after the procedure. Instead, it remains on the penis until the foreskin falls off naturally in seven to 10 days.
Choice B rationale
Yellow exudate, which is a normal part of the healing process, will form at the surgical site within 24 hours after a Plastibell circumcision. Parents should be reassured that this is not a sign of infection.
Choice C rationale
The end of the baby’s penis may appear dark red immediately after the procedure, but this should improve within a few days. If the redness persists or worsens, parents should notify the provider.
Choice D rationale
Ensuring that the newborn’s diaper is snug is not specific to the Plastibell circumcision technique. While a snug diaper can help prevent leaks, it should not be so tight as to cause discomfort or restrict circulation.
Correct Answer is D
Explanation
Choice A rationale
Storing a diaphragm in sterile water after each use is not necessary. After use, the diaphragm should be washed with mild soap and warm water, then air-dried.
Choice B rationale
Using an oil-based vaginal lubricant when inserting a diaphragm is not recommended. Oil- based lubricants can damage the material of the diaphragm, reducing its effectiveness.
Choice C rationale
Keeping the diaphragm in place for at least 4 hours after intercourse is correct, but it does not address the client’s postpartum status.
Choice D rationale
The client should have her provider refit her for a new diaphragm. After childbirth, a woman’s body undergoes changes that may affect the fit of her diaphragm. It is recommended that a woman be refitted for a diaphragm around 6 weeks postpartum, when the uterus and cervix have returned to normal size.
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