Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
18. A client, who is gravida 2, para 1, ruptures her membranes spontaneously with a large amount of clear fluid. A nurse performs a vaginal examination and discovers a loop of umbilical cord in the vagina. Which immediate action should be taken by the nurse?
. Place the client on her left side.
. Attempt to replace the cord.
. Elevate the client's hips.
. Cover the cord with a dry, sterile gauze.
Test-Taking Tip
The most important intervention is to relieve the umbilical cord compression. Covering the cord with a dry, sterile gauze causes a delay in relieving the compression. Eliminate the two options (Answers 2 and 4) that specifically focus on the visible cord. Focus on positioning the mother—one position releases cord compression and the other position (Answer 1) does not relieve the compression.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Medical Emergencies
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
.
Answer 1 is incorrect because placing the client on her left side does not relieve the umbilical cord compression that results in fetal bradycardia. Answer 2 is incorrect because it is contraindicated for the nurse to attempt to replace the cord. Answer 3 is correct because elevating the client's hips is the immediate intervention that helps to release the pressure from the umbilical cord until an emergency cesarean section can be performed. Answer 4 is incorrect because covering the cord with a dry, sterile gauze does not relieve the umbilical cord compression and the fetal bradycardia that results.