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: Failed to generate a rationale of 500+ characters after 5 retries.

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: Failed to generate a rationale of 500+ characters after 5 retries.

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.