Home » NCLEX » NCLEX-RN » In addition to changing the mother’s position to relieve cord pressure, the nurse may employ the following measure (s) in the event that she observes the cord out of the vagina:
In addition to changing the mother’s position to relieve cord pressure, the nurse may employ the following measure (s) in the event that she observes the cord out of the vagina:
A. Immediately pour sterile saline on the cord, and repeat this every 15 minutes to prevent drying.
B. Cover the cord with a wet sponge.
C. Apply a cord clamp to the exposed cord, and cover with a sterile towel.
D. Keep the cord warm and moist by continuous applications of warm, sterile saline compresses.
Correct Answer: D
Explanation/Reference:
Explanation:
(A) Saline should be warmed; waiting 15 minutes may not keep the cord moist. (B) This choice does not specify what the sponge was "wet" with. (C) This measure would stop circulation to the fetus. (D) The cord should be kept warm and moist to maintain fetal circulation. This measure is an accepted nursing action.
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