A nurse is caring for a client who is in labor and notes that the umbilical cord is prolapsed. Which of the following actions should the nurse take?

Place the client in Trendelenburg position.

Apply fundal pressure.

Loosely wrap the cord with petroleum gauze.

Evaluate uterine ton

Answer and Explanation

The Correct Answer is A

A. Place the client in Trendelenburg position: This position helps relieve pressure on the umbilical cord, potentially improving blood flow to the fetus. It is an appropriate immediate intervention for a prolapsed cord.

B. Apply fundal pressure: This is contraindicated in cases of cord prolapse as it can exacerbate the situation by pushing the presenting part further down and increasing pressure on the cord.

C. Loosely wrap the cord with petroleum gauze: While protecting the cord is important, simply wrapping it does not address the immediate need to relieve pressure and restore blood flow to the fetus.

D. Evaluate uterine tone: While assessing uterine tone is important during labor, the immediate priority when a prolapsed cord is noted is to relieve pressure on the cord to prevent fetal compromise. Therefore, this step should not be the first action taken.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A,B,C,D

Explanation

To delegate tasks to assistive personnel (APs) effectively, the nurse should follow this sequence:

A. Review the skill level and qualifications of each AP.
B. Communicate appropriate tasks to the APs with specific expectations.
C. Monitor progress of task completion with each AP.
D. Evaluate the APs' performance of each task.

This order ensures that the nurse first assesses the abilities of the APs, then clearly communicates tasks, monitors their progress, and finally evaluates their performance.

A. Direct statements to the interpreter. B. Pause in the middle of sentences. C. Speak in a normal voice at a natural pace. D. Use gestures when speaking with the client.

Correct Answer is C

Explanation

A) Direct statements to the interpreter: The nurse should speak directly to the client rather than the interpreter. While the interpreter facilitates communication, maintaining direct eye contact and addressing the client fosters a more personal and respectful interaction.

B) Pause in the middle of sentences: Pausing mid-sentence can confuse both the interpreter and the client, potentially leading to misunderstandings. It’s better to complete thoughts and allow the interpreter to relay the information in full.

C) Speak in a normal voice at a natural pace: This action is appropriate as it ensures that the client can understand the information being communicated. Speaking normally allows the interpreter to accurately convey the message without distortion or misinterpretation, which is essential for effective communication.

D) Use gestures when speaking with the client: While gestures can help with communication, they should be used carefully, as they may not always translate effectively across cultures. Relying too much on gestures can lead to misunderstandings or misinterpretations of the intended message. It's best to use clear verbal communication first, supplemented by gestures only as needed.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who is in labor and notes that the umbilical cord is prolapsed. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse has identified tasks to delegate to a group of assistive personnel (AP) after receiving change-of-shift report. Identify the sequence of steps the nurse should follow when delegating tasks to the APs. (Move the steps, placing them in the selected order of performance. Use all the steps.)

Correct Answer is A,B,C,D

Explanation

A nurse is caring for a client who speaks a different language than the nurse and is using an interpreter. Which of the following actions should the nurse take when working with the interpreter?

Correct Answer is C

Explanation

A nurse in the emergency department is assessing a newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following actions should the nurse take first?

A nurse is observing a newly licensed nurse who is administering total parenteral nutrition (TPN) to a client. Which of the following actions by the newly licensed nurse indicates a need for the nurse to intervene?

A nurse is admitting a client who has acute heart failure. Which of the following prescriptions from the provider should the nurse anticipate?

A nurse is caring for a client who is experiencing increased intracranial pressure following a head injury. In which of the following positions should the nurse place the client?

A nurse is caring for a client who has a prescription for 1 unit of packed RBCs. Five minutes after beginning the transfusion, the client becomes febrile with chills. After stopping the transfusion, which of the following actions should the nurse take?

A nurse is planning care for a client who is returning to the unit following open gastric bypass surgery. Which of the following interventions should the nurse include in the client's plan of care?

A nurse is caring for a client who has systemic lupus erythematosus. Which of the following client findings should the nurse expect?

A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include?