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?

Correct Answer: D

Rationale: The correct action for the nurse to perform first when observing the umbilical cord protruding from the vagina during the first stage of labor is to insert a gloved hand into the vagina to relieve pressure on the cord. This is crucial to prevent compression of the cord, which could compromise oxygenation to the fetus. By gently lifting the presenting part off the cord, the nurse can help maintain blood flow and prevent fetal distress. Once the pressure on the cord is relieved, additional interventions such as preparing the client for immediate birth, covering the cord with a sterile, moist saline dressing, or positioning the client in knee-chest position may be necessary depending on the clinical situation. But the priority is to relieve pressure on the umbilical cord promptly to ensure the well-being of the fetus.

Correct Answer: A

Rationale: In the management of preterm labor, the correct medication anticipated by the nurse is Prostaglandin E2 (Option A). Prostaglandin E2 is a medication commonly used to induce labor or ripen the cervix in preparation for labor in obstetric care. In the context of preterm labor, it can be used to promote uterine contractions to progress labor and potentially prevent further complications associated with preterm birth. Indomethacin (Option B) is a nonsteroidal anti-inflammatory drug that can be used to delay preterm labor by inhibiting prostaglandin synthesis. However, it is not the first-line medication choice for actively managing preterm labor. Magnesium sulfate (Option C) is often used to prevent seizures in preeclampsia/eclampsia and is not typically used to manage preterm labor directly. Methylergonovine (Option D) is a medication used to prevent or control postpartum hemorrhage by promoting uterine contractions after delivery, and it is not indicated for managing preterm labor. Understanding the appropriate pharmacological interventions in managing preterm labor is crucial for nurses working in maternal newborn care to ensure safe and effective patient outcomes. Prostaglandin E2 is selected in this scenario due to its role in promoting uterine contractions and advancing labor in the context of preterm birth.

Correct Answer: C

Rationale: Cold stress in a newborn can lead to an increase in oxygen consumption as the body works harder to maintain a normal body temperature. By minimizing oxygen consumption, the nursing intervention aims to prevent excessive oxygen demand and help the newborn cope with the cold stress more effectively. This can be achieved through methods such as swaddling, warming equipment, and ensuring the baby's environment is appropriately heated to maintain a stable body temperature. Minimizing oxygen consumption can help conserve energy and promote overall well-being in the newborn.

Correct Answer: C

Rationale: Administering vitamin K to a newborn is crucial to prevent bleeding disorders, specifically hemorrhagic disease of the newborn. Newborns have low levels of vitamin K at birth, which puts them at risk for hemorrhagic disease, a condition that can lead to severe bleeding, including intracranial hemorrhage. Vitamin K is essential for the production of clotting factors in the liver, which help the blood to clot effectively. By giving newborns a dose of vitamin K at birth, healthcare providers can prevent potential bleeding complications and ensure the baby's health and safety. Option A, preventing anemia, is incorrect because vitamin K does not play a significant role in preventing anemia in newborns. Anemia is usually related to iron deficiency or other factors, not vitamin K. Option B, enhancing immune function, is incorrect because while vitamin K is important for overall health, its primary role in newborns is related to blood clotting and preventing bleeding disorders, not directly related to immune function. Option D, promoting growth and development, is incorrect because although vitamin K is essential for overall growth and development, its immediate priority in newborns is to prevent bleeding disorders, as deficiencies can have serious consequences. Understanding the specific role of vitamin K in newborns' health is essential for healthcare providers working in maternal newborn care to ensure the best possible outcomes for their patients.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Proteinuria of +2 is the most concerning finding in a 36-week pregnant client. Proteinuria is the presence of abnormal levels of protein in the urine, which can indicate underlying issues like preeclampsia, a serious condition characterized by high blood pressure and organ damage. In a pregnant woman, particularly at 36 weeks, proteinuria can be a sign of preeclampsia, which requires immediate medical attention to prevent complications for both the mother and the baby. Now, let's discuss why the other options are not as concerning: A) Braxton Hicks contractions are common and considered normal in pregnancy, especially in the third trimester. They are usually irregular, mild, and do not indicate labor. B) Frequent urination is a common symptom in pregnancy due to hormonal changes and the growing uterus putting pressure on the bladder. While it can be uncomfortable, it is not typically a cause for concern. D) Weight gain of 2 pounds in a week is within the normal range for pregnancy, especially towards the end of the third trimester when the baby is growing rapidly. Sudden excessive weight gain or swelling, however, could be a sign of preeclampsia and should be monitored. Educationally, this question highlights the importance of recognizing concerning signs and symptoms in pregnant clients, especially those that could indicate severe conditions like preeclampsia. Understanding the significance of proteinuria in this context is crucial for nurses and healthcare providers to provide timely and appropriate care to ensure the well-being of both the pregnant individual and the unborn child.