The nurse, working in labor and delivery, performs a sterile vaginal exam on a laboring woman. During the exam, she feels a loop of pulsating cord in the vagina. The nurse would anticipate:
Select one:
Continuing to monitor and document fetal heart rate.
Changing the mother's position to left lateral and giving oxygen by nasal cannula.
With a sterile glove, maintaining pressure to lift the presenting part and emergently notifying the provider for a STAT C-section.
Bolusing the patient with 1000cc lactated ringers
The Correct Answer is C
Choice A Reason: Continuing to monitor and document fetal heart rate. This is an inadequate response that does not address the urgency of the situation or intervene to prevent fetal distress or demise.
Choice B Reason: Changing the mother's position to left lateral and giving oxygen by nasal cannula. This is a partial response that may improve maternal-fetal blood flow and oxygenation, but it does not resolve the cord compression or facilitate delivery.
Choice C Reason: With a sterile glove, maintaining pressure to lift the presenting part and emergently notifying the provider for a STAT C-section. This is an appropriate response that aims to reduce the cord compression by elevating the fetal head away from the cord and prepare for an immediate cesarean delivery.
Choice D Reason: Bolusing the patient with 1000cc lactated ringers. This is an irrelevant response that does not address the cause of the problem or improve fetal outcome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: Episodes of hypoglycemia and hyperglycemia. This is because episodes of hypoglycemia and hyperglycemia are common complications of diabetes during pregnancy, which can affect both the mother and the fetus. Hypoglycemia is a condition where the blood glucose level drops below the normal range, which can cause symptoms such as sweating, trembling, hunger, confusion, or loss of consciousness. Hyperglycemia is a condition where the blood glucose level rises above the normal range, which can cause symptoms such as thirst, polyuria, fatigue, blurred vision, or ketoacidosis. Diabetes during pregnancy requires careful monitoring and management of blood glucose levels to prevent adverse outcomes such as fetal macrosomia, congenital anomalies, stillbirth, or neonatal hypoglycemia.
Choice B Reason: Postpartum hemorrhage. This is an incorrect answer that refers to a different complication that may occur after delivery, not during pregnancy. Postpartum hemorrhage is excessive bleeding from the uterus or genital tract after delivery, which can cause hypovolemic shock, anemia, or death. Postpartum hemorrhage can be caused by uterine atony, retained placenta, lacerations, or coagulation disorders.
Choice C Reason: Cerebrovascular accident (CVA). This is an incorrect answer that indicates a rare and severe complication that may occur during or after pregnancy, not specifically related to diabetes. CVA is also known as stroke, which is an interruption of blood flow to the brain due to ischemia or hemorrhage, which can cause neurological deficits or death. CVA can be caused by hypertension, preeclampsia-eclampsia, thrombophilia, or vascular malformations.
Choice D Reason: Acute vasospasm. This is an incorrect answer that suggests a different condition that may occur during pregnancy, not associated with diabetes. Acute vasospasm is also known as Raynaud's phenomenon, which is a disorder of blood vessels that causes them to narrow and reduce blood flow to the extremities in response to cold or stress, which can cause pain, numbness, or color changes. Acute vasospasm can be triggered by smoking, medications, or autoimmune diseases.
Correct Answer is D
Explanation
Choice A Reason: Partial placenta previa is a condition where the placenta partially covers the cervix. It usually does not resolve and may cause bleeding and complications during labor and delivery.
Choice B Reason: Complete placenta previa is a condition where the placenta completely covers the cervix. It is a serious condition that requires cesarean delivery and may cause life-threatening hemorrhage.
Choice C Reason: Marginal placenta previa is a condition where the edge of the placenta reaches the margin of the cervix. It may also cause bleeding and complications during labor and delivery.
Choice D Reason: Low-lying placenta previa is a condition where the placenta is near the cervix, but not covering it. It may resolve spontaneously as the uterus grows and the placenta moves upward.
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