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

Answer and Explanation

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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Correct Answer is D

Explanation

Choice A Reason:
"The nurse will carry your newborn to the nursery for procedures. "This statement is inappropriate. In current practice, there is an emphasis on family-centered care, and parents are often encouraged to be involved in the care of their newborns, including accompanying them for procedures whenever possible.

Choice B Reason:
"We will document the relationship of visitors in your medical record." This statement is inappropriate. While it is important to monitor and document visitors, the primary focus here is on healthcare staff and their identification.

Choice C Reason:
"Your baby will stay in the nursery while you are asleep." This statement is inappropriate. Promoting rooming-in and encouraging parental involvement in newborn care is a common practice to support bonding and breastfeeding, so this statement may not align with current best practices.

Choice D Reason:
"Staff members who take care of your baby will be wearing a photo identification badge." This statement reassures the client that the healthcare providers involved in the care of the newborn will have proper identification, enhancing security and ensuring that authorized personnel are handling the infant.

A. Assist the client to turn onto her side. B. Assist the client to an upright position. C. Prepare for a cesarean birth D. Prepare for an immediate vaginal delivery.

Correct Answer is A

Explanation

The correct answer is A. Assist the client to turn onto her side.

A. Assisting the client to turn onto her side is the correct intervention. This is because the client's blood pressure is low, and turning onto the side helps improve blood flow to the uterus, reducing the risk of supine hypotension.

B. Assisting the client to an upright position is not the priority in this case. The client is at risk for supine hypotension, and a lateral position is more appropriate.

C. Preparing for a cesarean birth is not indicated based solely on the blood pressure reading. Turning the client onto her side and monitoring the blood pressure response are appropriate initial actions.

D. Preparing for an immediate vaginal delivery is not indicated based solely on the blood pressure reading. The client's condition may improve with positional changes, and further assessment is needed.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a postpartum client about steps the nurses will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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