Review Nursing interventions and management

Umbilical cord prolapse > Maternal & Newborn

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Nursing interventions and management

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Total Questions : 4

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Question 1:

A nurse is caring for a client who is in labor and has a prolapsed umbilical cord.

Which of the following actions should the nurse take first?

A. Apply a warm, sterile, saline-soaked towel to the visible cord B. Administer oxygen at 8 to 10 L/min via a face mask C. Call for assistance and notify the provider D. Reposition the client to a knee-chest position

Answer and Explanation

Choice A:

Applying a warm, sterile, saline-soaked towel to the visible cord is not the first action to take.This intervention can prevent drying and atrophy of the umbilical vessels, but it does not relieve cord compression.

Choice B:

Administering oxygen at 8 to 10 L/min via a face mask is not the first action to take.This intervention can increase fetal oxygenation, but it does not relieve cord compression.

Choice C:

Calling for assistance and notifying the provider is not the first action to take.This intervention is necessary to prepare for emergency delivery, but it does not relieve cord compression

Choice D:

This position can reduce the pressure of the fetal presenting part on the prolapsed cord and improve fetal oxygenation.The nurse should also call for assistance and notify the provider, administer oxygen at 8 to 10 L/min via a face mask, and apply a warm, sterile, saline-soaked towel to the visible cord, but these are not the first actions to take.

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Question 2:

A nurse is reviewing the risk factors for umbilical cord prolapse with a group of nursing students.

Which of the following factors should the nurse include? (Select all that apply.).

A. Premature rupture of membranes B. Breech presentation C. Cephalopelvic disproportion D. Gestational diabetes E. Hydramnios

Answer and Explanation

Choice A:

This can cause the cord to slip past the fetal head or limbs when the amniotic fluid gushes out.

Choice B:

This is when the fetus is positioned with its feet or buttocks first. In a footling breech, the cord can easily slip between and past the fetal feet and into the pelvis.

Choice C:

This is when the fetal head is too large to fit through the maternal pelvis. This is not a risk factor for cord prolapse, as the fetal head usually prevents the cord from descending.

Choice D:

This is a condition where the mother has high blood sugar levels during pregnancy. This can cause macrosomia (large baby), but this is not a direct risk factor for cord prolapse.

Choice E:

This is a condition where there is excessive amniotic fluid around the fetus. This can create more space for the cord to move and prolapse, especially if there is a sudden loss of fluid.

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Question 3:

A nurse is monitoring a client who is in labor and has meconium-stained amniotic fluid.

The nurse should identify that this finding can indicate which of the following conditions?

A. Fetal hypoxia B. Fetal infection C. Fetal maturity D. Fetal distress

Answer and Explanation

Choice A:

Meconium-stained amniotic fluid is often caused by fetal hypoxia or other physiologic stress.Any reflexive “gasping” of the unborn fetus, due to hypoxia, can depress the fetal diaphragm mechanically, squeezing the contents of the bowels into the amniotic fluid.Meconium is a sign of fetal distress, either on-going or old.

Choice B:

Meconium-stained amniotic fluid is not a direct indicator of fetal infection.However, fetal infection can cause fetal hypoxia and distress, which can lead to meconium passage.

Choice C:

Meconium-stained amniotic fluid is not a sign of fetal maturity.It is more common in full-term or post-term babies, but it can also occur in preterm babies.

Choice D:

It is too vague and nonspecific.Fetal distress can have many causes and manifestations, such as abnormal heart rate patterns, reduced fetal movements, or acidosis.

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Question 4:

A nurse is performing a vaginal examination on a client who is in labor and notices a loop of umbilical cord protruding from the vagina.

Which of the following actions should the nurse take to relieve pressure on the cord?

A. Push the cord back into the vagina with a sterile gloved hand. B. Place two fingers on either side of the cord and lift the fetal head off of it C. Clamp and cut the cord with sterile scissors D. Pull gently on the cord to facilitate delivery

Answer and Explanation

Choice A:

Pushing the cord back into the vagina can cause more damage to the cord and increase the risk of infection.

Choice B:

This action can relieve pressure on the cord and prevent fetal hypoxia until delivery can take place.

Choice C:

Clamping and cutting the cord will cut off the fetal blood supply and result in fetal death.

Choice D:

Pulling gently on the cord can cause cord avulsion or rupture of the uterus, both of which are life-threatening complications.

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Total Questions : 4

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Nursing interventions and management

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