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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) "I should use a soft-bristle toothbrush to clean my teeth after meals.": Using a soft-bristle toothbrush is crucial for clients with stomatitis, as it minimizes irritation to sensitive oral tissues. Gentle oral hygiene practices help maintain oral health and reduce discomfort, indicating that the client understands the need for careful dental care during radiation therapy.
B) "I should limit my intake of dairy products to prevent nausea.": While some clients may experience nausea, limiting dairy is not typically recommended for managing stomatitis. In fact, dairy can be soothing for some individuals. This statement does not address the specific needs related to stomatitis and indicates a misunderstanding of dietary management during treatment.
C) "I should gargle with an alcohol-based mouthwash to kill germs.": Alcohol-based mouthwashes can further irritate the mucous membranes and exacerbate stomatitis symptoms. Acknowledging this would demonstrate a lack of understanding, as alcohol is contraindicated in the management of oral mucosal irritation caused by radiation therapy.
D) "I should moisten my lips with lemon-glycerin swabs.": Lemon-glycerin swabs can actually irritate the mouth and exacerbate discomfort in clients with stomatitis. This approach is not recommended, and selecting such a treatment indicates a misunderstanding of appropriate oral care measures during radiation therapy.
Correct Answer is C
Explanation
A) Educating clients about contraindications to specific immunizations: This task relates more to primary prevention, as it aims to prevent disease by informing clients about vaccine safety and appropriateness.
B) Helping clients understand health screenings covered by their insurance plans: This is also more aligned with primary prevention, as it focuses on the importance of screenings to detect health issues early.
C) Using an electronic messaging system to remind clients when to take medications: This is the correct answer. Tertiary prevention focuses on managing and improving the quality of life for individuals with chronic conditions, such as HIV. Reminding clients to take their medications helps prevent disease progression and complications.
D) Providing clients with information about the benefits of exercise: While exercise is beneficial for health, this task is more associated with promoting general health and wellness, aligning with primary prevention efforts rather than tertiary prevention.
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