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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A Reason: Pulmonary edema is a condition where ﬂuid accumulates in the lungs, causing shortness of breath and difficulty breathing. It can occur in preeclampsia due to increased blood pressure and ﬂuid retention, but it is not a definitive sign of eclampsia.

Choice B Reason: Convulsion (seizure) is a sudden, involuntary contraction of muscles that can cause loss of consciousness, shaking, and twitching. It is the main symptom of eclampsia and distinguishes it from preeclampsia.

Choice C Reason: Renal failure is a condition where the kidneys fail to filter waste products from the blood, resulting in high levels of creatinine and urea. It can occur in preeclampsia due to reduced blood ﬂow to the kidneys, but it is not a specific indicator of eclampsia.

Choice D Reason: Retinal edema is a condition where ﬂuid leaks into the retina, causing blurred vision and ﬂashes of light. It can occur in preeclampsia due to increased blood pressure and damage to the blood vessels in the eye, but it is not a characteristic feature of eclampsia.

A. Frequent voiding encourages sphincter control. B. A full bladder impedes oxygen ﬂow to the fetus. C. Frequent voiding prevents bruising of the bladder. D. A full bladder can impede fetal descent.

Correct Answer is D

Explanation

Choice A Reason: Frequent voiding encourages sphincter control. This is an incorrect statement that has no relevance to labor and delivery. Sphincter control refers to the ability to contract and relax the muscles that control urination and defecation. It is not aﬀected by frequent voiding.

Choice B Reason: A full bladder impedes oxygen ﬂow to the fetus. This is an incorrect statement that confuses a full bladder with a prolapsed cord. A prolapsed cord is a condition where the umbilical cord slips through the cervix before the baby and becomes compressed by the fetal head, which can reduce oxygen ﬂow to the fetus. A full bladder does not aﬀect oxygen ﬂow to the fetus.

Choice C Reason: Frequent voiding prevents bruising of the bladder. This is an incorrect statement that exaggerates the eﬀect of a full bladder on the bladder wall. A full bladder may cause some pressure or discomfort on the bladder, but it does not cause bruising or damage.

Choice D Reason: A full bladder can impede fetal descent. This is a correct statement that explains why it is important for the nurse to assess the bladder regularly and encourage the laboring client to void every 2 hours.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The primary factor that diﬀerentiates eclampsia from preeclampsia is: Select one:

Correct Answer is B

Explanation

Why is it important for the nurse to assess the bladder regularly and encourage the laboring client to void every 2 hours? Select one:

Correct Answer is D

Explanation

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The client at 42 weeks' pregnancy is admited for induction of her labor. Which statement indicates that she understands the Reasons for the induction? Select one:

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: