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 A
Explanation
A. After notifying the provider, the nurse should massage the client’s fundus. This action helps to contract the uterus and reduce bleeding, which is crucial in managing hypovolemic shock due to postpartum hemorrhage.
B. Insert an indwelling urinary catheter: This action is important for monitoring urine output, which is a key indicator of renal perfusion and overall fluid status. However, it is not the immediate priority when managing hypovolemic shock due to postpartum hemorrhage.
C. Administer oxygen at 10 L/min: Providing oxygen is crucial to ensure adequate tissue oxygenation, especially in a shock state. While important, it comes after addressing the source of bleeding, which is the primary cause of the hypovolemic shock.
D. Elevate the client’s right hip: This action helps to prevent uterine displacement and improve venous return, which can be beneficial. However, it is not the first step in managing hypovolemic shock due to postpartum hemorrhage.
Correct Answer is A
Explanation
A. "This medication promotes softening of the cervix."
A. Dinoprostone is a prostaglandin E2 analogue that is used to ripen the cervix by promoting softening and effacement. This is an important step in preparing the cervix for labor induction or augmentation.
B. Dinoprostone does not cause relaxation of the uterine muscles. Instead, it specifically works on the cervix to make it more favorable for labor.
C. Dinoprostone is not used to treat preeclampsi
A. It is primarily used for cervical ripening in the context of labor induction or augmentation.
D. Dinoprostone is not used to treat genital herpes simplex virus. It is specifically employed for its effects on cervical ripening and preparing the cervix for labor.
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