Author Question: Which nursing action should be initiated first when there is evidence of prolapsed cord? a. ... (Read 70 times)

formula1 · **on:** Jun 28, 2018

Which nursing action should be initiated first when there is evidence of prolapsed cord?

a. Notify the health care provider.
b. Apply a scalp electrode.
c. Prepare the mother for an emergency cesarean birth.
d. Reposition the mother with her hips higher than her head.

Question 2

After a birth complicated by a shoulder dystocia, the infant's Apgar scores were 7 at 1 minute and 9 at 5 minutes. The infant is now crying vigorously. The nurse in the birthing room should:

a. palpate the infant's clavicles.
b. encourage the parents to hold the infant.
c. perform a complete newborn assessment.
d. give supplemental oxygen with a small face mask.

zacnyjessica · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: D
The priority is to relieve pressure on the cord. Changing the maternal position will shift the position of the fetus so that the cord is not compressed. Notifying the health care provider is a priority but not the first action. It would not be appropriate to apply a scalp electrode at this time. Preparing the mother for a cesarean birth would not be the first priority.

Answer to Question 2

ANS: A
Because of the shoulder dystocia, the infant's clavicles may have been fractured. Palpation is a simple assessment to identify crepitus or deformity that requires follow-up. The infant needs to be assessed for clavicle fractures before excessive movement. A complete newborn assessment is necessary for all newborns, but assessment of the clavicle is top priority for this infant. The Apgar indicates that no respiratory interventions are needed.