Nursing interventions and management
Nursing interventions and management ( 4 Questions)
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?
Pushing the cord back into the vagina can cause more damage to the cord and increase the risk of infection.
This action can relieve pressure on the cord and prevent fetal hypoxia until delivery can take place.
Clamping and cutting the cord will cut off the fetal blood supply and result in fetal death.
Pulling gently on the cord can cause cord avulsion or rupture of the uterus, both of which are life-threatening complications.
The correct answer is choice B. Place two fingers on either side of the cord and lift the fetal head off of it.
This action can relieve pressure on the cord and prevent fetal hypoxia until delivery can take place.
Choice A is wrong because pushing the cord back into the vagina can cause more damage to the cord and increase the risk of infection.
Choice C is wrong because clamping and cutting the cord will cut off the fetal blood supply and result in fetal death.
Choice D is wrong because pulling gently on the cord can cause cord avulsion or rupture of the uterus, both of which are life-threatening complications.
Normal ranges for umbilical cord pH are 7.18 to 7.38 and for umbilical cord base excess are -8 to +2 mmol/L.
: Cord Prolapse Nursing Management - RNpedia