Practice Question
A nurse is caring for 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 perform first?
Answer Choices:
Correct Answer:
Insert a gloved hand into the vagina to relieve pressure on the cord.
Rationale:
✅ Immediate priority — Restores fetal oxygenation by relieving pressure.
✅ Manual lifting of presenting part — Decreases cord occlusion.
✅ Prevents severe hypoxia — Maintains circulation until delivery.
✅ Followed by repositioning — Use knee-chest or Trendelenburg.
✅ Emergency prep — Immediate cesarean anticipated.
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This question is from Custom RN~Maternity Assessment 3, Taylor College FL-ADN which contains 110 questions.
More Questions from This Exam
A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?
Answer Choices:
A. Late decelerations
B. Accelerations
C. Variable decelerations
D. Early decelerations
A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn's nose and mouth. Which of the following actions is the nurse's priority?
Answer Choices:
A. Suction the mouth with a bulb syringe,
B. Turn the newborn on his side.
C. Suction the nose with a bulb syringe.
D. use a suction catheter with low negative pressure.
A nurse is caring for a client who is 7 days postpartum and calls the clinic to report pain and redness of her left calf. Besides seeing her provider, which of the following interventions should the nurse suggest?
Answer Choices:
A. Massage the area,
B. Apply cold compresses.
C. Flex her knee while resting.
D. Elevate her leg.
A nurse is preparing to administer vitamin K by 1M injection to a newborn. The nurse should administer the medication into which of the following muscles?
Answer Choices:
A. Deltoid
B. Dorsogluteal
C. Vastus lateralis
D. Ventrogluteal
A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period.Which of the following is the priority nursing intervention at this time?
Answer Choices:
A. Assist the client on a bedpan to urinate.
B. Prepare to administer oxytocic medication.
C. Palpate the client's uterine fundus,
D. Increase the client's fluid intake.
From Exam
Custom RN~Maternity Assessment 3, Taylor College FL-ADN
110 Questions
View Full Exam Start PracticingQuestion Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN Custom Exam(s)
- Answer Choices: 4