A pregnant client admitted to the labor room arrived with a fetal heart rate (FHR) of 94 beats/min and the umbilical cord protruding from the vagina. The client states that her "water broke" before coming to the hospital
The most appropriate nursing action would be to: 1. Sit the client in a high Fowler's position.
2. Call the pharmacy for a tocolytic medication.
3. Get intravenous (IV) therapy equipment and solution from the storage area.
4. Wrap the cord loosely in a sterile towel soaked with warm, sterile normal saline.
4
Rationale: When an umbilical cord is protruding, the cord must be protected from drying out and from becoming compressed. Wrapping the cord with a sterile, saline-soaked towel will help ac-complish this. The nurse must also help reduce compression of the cord by placing the client in an extreme Trendelenburg's or modified Sims position. A tocolytic would be used if the client had inadequate uterine relaxation. IV solutions may be administered but are not the priority item with the information given.
You might also like to view...
A nurse researcher would want to use a Kuder-Richardson (KR-20) coefficient to establish the internal consistency of an instrument in which case?
a. When questions are open-ended b. When multiple choice tests are analyzed c. When the instrument uses a Likert-type response scale d. When the instrument is designed to measure more than one concept
During a physical examination a young patient asks for information about birth control. What information in the patient's history should the nurse use to guide teaching?
Select all that apply. 1. multiple sex partners 2. no use of condoms 3. lives with grandmother 4. aged 15 5. allergic to penicillin
The nurse is providing prenatal care to a young couple that is pregnant with their first child. In what period of development would the nurse explain to the couple that most congenital defects would occur?
A) The period of the zygote B) The period of the embryo C) The period of the fetus D) All periods are equally vulnerable
A nurse is assigned to work in the administrative office of a health maintenance
organization. What duty does the nurse have to perform? A) Providing end-of-life care B) Working as wellness coordinator C) Maintaining health of employees D) Interviewing healthcare personnel