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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The cervix being effaced is not represented by the -1 notation in a vaginal examination. Effacement is usually expressed as a percentage.
B. The -1 notation does not represent cervical dilation. Dilation is measured in centimeters.
C. The presenting part being 1 cm below the ischial spines is not correct. In the station system, if the presenting part is above the ischial spines, it is represented by a negative number. A -1 station indicates that the presenting part is 1 cm above the ischial spines.
D. The presenting part is 1 cm above the ischial spines is the correct interpretation.
In the station system, if the presenting part is above the ischial spines, it is represented by a negative number. A -1 station indicates that the presenting part is 1 cm above the ischial spines.
Correct Answer is A
Explanation
The correct answer is A. Blood pressure 80/56 mm Hg.
A. A blood pressure of 80/56 mm Hg is the priority finding. Opioid analgesia can cause hypotension, and addressing low blood pressure is crucial to prevent maternal and fetal complications. The nurse should notify the healthcare provider promptly and implement interventions to improve blood pressure.
B. Profuse itching is a common side effect of opioids and is generally not considered a priority unless it becomes severe or is accompanied by other concerning symptoms.
C. A temperature of 38.2°C (100.8°F) may indicate a fever, but addressing hypotension takes precedence. Elevated temperature can be further assessed but is not the priority in this scenario.
D. The client reporting weakness of the lower extremities is a concerning symptom, but the priority is to address hypotension first, as it could be related to opioid-induced hypotension.
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