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?

Insert a gloved hand into the vagina to relieve pressure on the cord.

Cover the cord with a sterile, moist saline dressing.

Place the client in knee-chest position.

Prepare the client for an immediate birth.

Answer and Explanation

The Correct Answer is C

A) Insert a gloved hand into the vagina to relieve pressure on the cord: While this action may be necessary in some cases, the priority in this situation is to relieve pressure on the umbilical cord to prevent cord compression. Placing the client in the knee-chest position is the most appropriate initial action to achieve this.
B) Cover the cord with a sterile, moist saline dressing: Applying a sterile, moist saline dressing is typically done after taking steps to relieve pressure on the umbilical cord. While it is important to keep the cord moist and protected, it is not the first action to take in this emergency situation.
C) Place the client in knee-chest position: Placing the client in the knee-chest position helps to relieve pressure on the umbilical cord by shifting the weight of the uterus off the cord. This position can help prevent cord compression and maintain fetal oxygenation, making it the priority action in this situation.
D) Prepare the client for an immediate birth: While preparing for a possible emergency birth may be necessary if the client is close to delivering, the immediate concern is relieving pressure on the umbilical cord to prevent fetal compromise. Placing the client in the knee-chest position should be the first action taken by the nurse to address the cord prolapse.

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Correct Answer is D

Explanation

A) Accelerations:
Accelerations in the fetal heart rate are generally considered a reassuring sign and indicate fetal well-being. They reflect a responsive and healthy fetus.

B) Late decelerations:
Late decelerations are associated with uteroplacental insufficiency and indicate that the fetus may not be getting enough oxygen. While this is a concerning pattern, it is not specifically indicative of an umbilical cord problem.

C) Early decelerations:
Early decelerations are typically caused by fetal head compression during contractions and are generally considered benign. They usually do not indicate a problem with the umbilical cord.

D) Variable decelerations:
Variable decelerations are often caused by umbilical cord compression. They are characterized by abrupt decreases in fetal heart rate that vary in duration, intensity, and timing relative to uterine contractions. This pattern is indicative of issues with the umbilical cord, such as cord prolapse or nuchal cord (cord wrapped around the fetus's neck). Therefore, variable decelerations are the pattern most suggestive of a problem with the umbilical cord.

A. Right upper B. Right lower C. Left lower D. Left upper

Correct Answer is A

Explanation

A) Right upper:
Given the findings from Leopold maneuvers—a round, firm, moveable part (likely the fetal head) in the fundus and a long, smooth surface (the fetal back) on the client's right side—this suggests that the fetus is in a breech position (head up, buttocks down). Therefore, the fetal heart tones would be best auscultated in the right upper quadrant.

B) Right lower:
If the fetus were in a cephalic (head-down) position, the fetal heart tones would typically be auscultated in the lower quadrants. However, the findings indicate a breech position, so this is not the correct answer.

C) Left lower:
This would be appropriate for a fetus in a cephalic position with the back on the left side, but the findings indicate the back is on the right side and the head is in the fundus.

D) Left upper:
This would be unlikely based on the findings of the head in the fundus and the back on the right side. The fetal heart tones would not be expected here.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?

Correct Answer is D

Explanation

A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the fundus of the uterus and a long, smooth surface on the client's right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones?

Correct Answer is A

Explanation

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