ATI PN Maternity
ATI PN Maternity ( 62 Questions)
A nurse is assisting with the care of a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse take first?
Preparing the client for an emergency cesarean birth might be necessary if there's a prolapsed cord, but it's not the first action to take. The nurse needs to stabilize the situation and protect the cord before considering any other interventions.
While explaining to the client what is happening is essential for informed consent and to reduce anxiety, it is not the first priority when the umbilical cord is protruding. Immediate action to protect the cord and the baby is necessary.
Covering the cord with a sterile, moist saline dressing is the first and most crucial step to take. This helps to prevent the cord from drying out and reduces the risk of infection. The nurse should gently push the presenting part of the baby off the cord and cover it with a sterile, moist dressing.
Placing the client in a knee-chest or Trendelenburg position might be indicated in some cases of cord prolapse, but it is not the first action to take. Covering the cord takes precedence to protect the baby's oxygen supply.
Choice A rationale:
Preparing the client for an emergency cesarean birth might be necessary if there's a prolapsed cord, but it's not the first action to take. The nurse needs to stabilize the situation and protect the cord before considering any other interventions.
Choice B rationale:
While explaining to the client what is happening is essential for informed consent and to reduce anxiety, it is not the first priority when the umbilical cord is protruding. Immediate action to protect the cord and the baby is necessary.
Choice C rationale:
Covering the cord with a sterile, moist saline dressing is the first and most crucial step to take. This helps to prevent the cord from drying out and reduces the risk of infection. The nurse should gently push the presenting part of the baby off the cord and cover it with a sterile, moist dressing.
Choice D rationale:
Placing the client in a knee-chest or Trendelenburg position might be indicated in some cases of cord prolapse, but it is not the first action to take. Covering the cord takes precedence to protect the baby's oxygen supply.