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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Confirming the newborn's Apgar score is important for assessing the newborn's overall condition, but it may not be the first priority.
Choice B Reason:
Verifying the newborn's identification is appropriate. Ensuring accurate identification is a crucial step in newborn care to prevent errors and ensure that interventions are carried out on the correct infant.
Choice C Reason:
Administering vitamin K is a standard practice but can wait until after the newborn's identification is confirmed.
Choice D Reason:
Determining obstetrical risk factors is part of the overall assessment but is not the immediate priority in this situation.
Correct Answer is D
Explanation
A. Contractions lasting longer than 90 seconds: Prolonged contractions lasting longer than 90 seconds may indicate uterine hyperstimulation, which can compromise fetal oxygenation and lead to fetal distress. This finding should be reported to the provider promptly for further evaluation and management.
B. Client reports feeling contractions in the lower back: This is a common sensation during labor and may not necessarily indicate a complication. However, if associated with other signs of fetal distress, it should be reported.
C. Contractions occurring every 3 to 5 minutes: This frequency is within the normal range for the active phase of labor and does not necessarily indicate a problem. However, it is essential to consider the duration and intensity of contractions along with this frequency.
D. Contractions are strong in intensity: While strong contractions are typical during the active phase of labor, the intensity alone may not be a cause for concern unless they are associated with uterine hyperstimulation.
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