问题 单项选择题

Immediately after a spontaneous rupture of the membranes, the nurse observes a loop of umbilical cord protruding from the vagina. What should the nurse do first

A.Administer oxygen.

B.Notify the physician.

C.Document the deceleration.

D.Elevate the hips on two pillows.

答案

参考答案:D

解析:The first nursing action would be to elevate the hips on two pillows. The primary goal with prolapse of the umbilical cord is to remove the pressure from the cord. Changing the maternal position is the first intervention. Acceptable positions include knee-chest, side-lying, and elevation of the hips. The nurse may also perform a vaginal examination and attempt to push the presenting part of the cord while being careful not to add any pressure to the cord.

单项选择题
单项选择题 A1/A2型题