NURSING FUNDAMENTALS HEALTH CARE A EXAM A GRADE QUESTIONS WITH ANSWERS AND RATIONALES UPDA, Exams for Nursing

A laboring client at –2 station has a spontaneous rupture of the membranes and a cord immediately protrudes from the vagina. The highest priority is which of the following? a. Place gentle pressure upward on the fetal head b. Place the cord back into the vagina to keep it moist c. Begin oxygen by face mask at 8-10l/min d. Turn the client of her left side ANSWER: A RATIONALE: The nurse should place her hand on the fetal head and provide gentle upward pressure to relieve the compression on the cord. Doing so allows oxygen to continue flowing to the fetus. The cord should never be placed back into the vagina because doing so may further compress it. Administering oxygen is an appropriate measure but will not serve a useful purpose until the pressure is relieved on the cord enabling perfusion to the infant. Turning the client to her left side facilitates better perfusion to the mother but until the compression on the cord is relieved the increased oxygen will not serve its purpose. Placing the client in a trendelenburg would be position changes to increase perfusion to then infant by relieving cord compression