The nurse notices a decreased fetal heart rate (FHR) on the fetal monitor tracing and contacts the charge nurse. The charge nurse completes a vaginal exam and can feel a portion of the umbilical cord in the vagina.
Which emergency interventions will the charge nurse implement? Select all that apply.
Prepare the client for emergency cesarean delivery
Position the client in a knee-chest position and call for help
Locate and insert a vacuum suction catheter into the vagina and push the infant back into the uterus
Keep a gloved hand in the vagina and push upward on the presenting part to keep it off the cord
Contact the provider and report a prolapsed umbilical cord
Correct Answer : A,B,D,E
A. Preparing the client for emergency cesarean delivery is often necessary when a prolapsed umbilical cord is identified.
B. Positioning the client in a knee-chest position helps alleviate pressure on the umbilical cord, improving fetal oxygenation.
C. Inserting a vacuum suction catheter into the vagina and pushing the infant back into the uterus is not a recommended intervention for a prolapsed umbilical cord; this action may cause harm to the fetus.
D. Keeping a gloved hand in the vagina and pushing upward on the presenting part helps relieve pressure on the umbilical cord.
E. Contacting the provider and reporting a prolapsed umbilical cord is essential for prompt communication and decision-making.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Late decelerations typically start after the contraction has reached its peak and return to baseline after the contraction ends, not during the contraction.
B. Early decelerations coincide with the contraction and return to baseline by the end of the contraction. They are typically considered benign and related to head compression.
C. Accelerations are brief increases in the FHR above the baseline and are usually associated with fetal movement.
D. Variable decelerations are abrupt decreases in the FHR, often unrelated to contractions, and have an erratic pattern.
Correct Answer is B
Explanation
A. Placing the client on her left side is important for optimizing fetal oxygenation but is not the first action when there is a report of a gush of fluid.
B. Notifying the registered nurse (RN) immediately is the first action to ensure prompt assessment and appropriate interventions for possible ruptured membranes.
C. Documenting the time and color of the fluid is important, but immediate notification of the RN takes precedence.
D. Checking fetal heart tones is important but should be done in conjunction with notifying the RN to assess the overall situation and determine the appropriate course of action.
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