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 C

Explanation

Choice A Reason: IgG. This is an incorrect answer that refers to a diﬀerent type of antibody that is not abundant in breast milk. IgG is a type of antibody that provides systemic immunity against various antigens. IgG is found in low concentrations in breast milk, as it does not cross the mammary epithelium easily. IgG can protect the infant from some infections, but it is mainly transferred from the mother to the fetus through the placenta during pregnancy.

Choice B Reason: IgE. This is an incorrect answer that refers to a diﬀerent type of antibody that is not relevant to breast milk. IgE is a type of antibody that mediates allergic reactions and parasitic infections. IgE is found in very low concentrations in breast milk, as it does not have a significant role in mucosal immunity. IgE can trigger mast cells and basophils to release histamine and other inﬂammatory mediators, which can cause symptoms such as itching, swelling, or bronchoconstriction.

Choice C Reason: IgA. This is because IgA is a type of antibody that protects mucosal surfaces from pathogens and toxins. IgA is found in high concentrations in breast milk, especially in colostrum (the first milk produced after delivery). IgA can bind to bacteria and viruses in the infant's gastrointestinal tract and prevent them from ataching to the intestinal wall or crossing into the bloodstream. IgA can also enhance the infant's immune system by stimulating lymphoid tissue development and modulating inﬂammatory responses.

Choice D Reason: IgM. This is an incorrect answer that refers to a diﬀerent type of antibody that is not abundant in breast milk. IgM is a type of antibody that activates complement system and agglutinates antigens. IgM is found in low concentrations in breast milk, as it does not cross the mammary epithelium easily due to its large size. IgM can protect the infant from some infections, but it is mainly produced by the infant's own immune system in response to exposure to antigens.

A. Maintain the client on strict bedrest. B. Carefully monitor intake and output. C. Restrict visitation of the client's partner. D. Closely supervise all infant care and interaction.

Correct Answer is D

Explanation

Choice A Reason: Maintain the client on strict bedrest. This is an inappropriate action that may worsen the client's condition and increase her isolation and depression. Postpartum psychosis requires prompt psychiatric treatment with medication and psychotherapy, not bedrest.

Choice B Reason: Carefully monitor intake and output. This is an irrelevant action that has no direct relation to postpartum psychosis or its management. Monitoring intake and output may be indicated for other postpartum complications such as hemorrhage, infection, or preeclampsia.

Choice C Reason: Restrict visitation of the client's partner. This is an unnecessary action that may deprive the client of social support and emotional comfort. The partner may be an important source of help and information for the client and the health care team. The partner should be involved in the client's care and education, unless there are signs of abuse or violence.

Choice D Reason: Closely supervise all infant care and interaction. This is because postpartum psychosis is a severe mental disorder that occurs in some women after childbirth, which can cause delusions, hallucinations, paranoia, mood swings, confusion, and suicidal or homicidal thoughts. Postpartum psychosis can pose a danger to both the mother and the infant, as the mother may harm herself or the infant due to distorted perceptions or impulses. The nurse should closely supervise all infant care and interaction to ensure safety and prevent injury.

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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

An nurse is counseling a new mother about the immunologic properties of breast milk. The nurse emphasizes that breast milk is the main source of which specific immunoglobulin? Select one:

Correct Answer is C

Explanation

A client has been diagnosed with postpartum psychosis. Which of the following actions should the nurse take? Select one:

Correct Answer is D

Explanation

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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:

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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: