A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?
Cover the cord with a sterile, moist saline dressing
Place the client in knee-chest position
Insert a gloved hand into the vagina to relieve pressure on the cord
Prepare the client for an immediate birth
The Correct Answer is C
The correct answer is C. Insert a gloved hand into the vagina to relieve pressure on the cord.
A. Covering the cord with a sterile, moist saline dressing is a potential action, but relieving pressure on the cord takes precedence. This can be done by manually elevating the presenting part of the fetus off the cord.
B. Placing the client in a knee-chest position may be recommended after taking the immediate action of relieving pressure on the cord. Elevating the hips may help reduce cord compression.
C. Inserting a gloved hand into the vagina to relieve pressure on the cord is the priority action.
By manually lifting the presenting part off the cord, the nurse can help restore blood flow to the fetus and prevent umbilical cord compression.
D. Preparing the client for an immediate birth may be necessary, but the immediate action to relieve pressure on the cord should be performed first. The healthcare provider will determine the need for urgent delivery based on the clinical situation.
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Related Questions
Correct Answer is C
Explanation
A. Instructing the client to increase her respiratory rate to more than 42 breaths per minute may exacerbate hyperventilation and cause respiratory alkalosis. This is not the appropriate action in this situation.
B. Breathing into a paper bag is an outdated and potentially dangerous practice. It can lead to a buildup of carbon dioxide in the body and may have adverse effects on both the mother and the baby. It is not recommended.
C. Having the client tuck her chin to her chest is the correct action.
This maneuver helps decrease the respiratory rate and prevent hyperventilation. It promotes a controlled and appropriate breathing pattern during labor.
D. Administering oxygen via nasal cannula is not the first-line intervention for lightheadedness and tingling during labor. The client's symptoms are likely due to hyperventilation, and addressing the breathing pattern is more appropriate.
Correct Answer is C
Explanation
Choice A Reason:
Hemoglobin (Hgb) of 20 g/dL is elevated, but this can be a normal finding in a newborn and does not necessarily require immediate intervention.
Choice B Reason:
Total bilirubin of 5 mg/dL is within the normal range for a 24-hour-old newborn.
Choice C Reason:
Blood glucose 30 mg/dL. A blood glucose level of 30 mg/dL is significantly lower than the normal range for a newborn. Hypoglycemia in a newborn can lead to neurologic complications, so it is important to report this result promptly for further evaluation and intervention.
Choice D Reason:
White blood cell (WBC) count of 20,000/mm³ is within the expected range for a newborn and is not a cause for immediate concern. Newborns often have higher WBC counts shortly after birth.
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