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 D
Explanation
A) Noting changes in the treatment plan in the client's medical record: While this is important for continuity of care, it may not directly facilitate communication among staff in real-time or promote a collaborative approach.
B) Recording the client's progress in the nurses' notes: Documenting progress is essential, but it serves more as a record of care rather than an active communication tool among the team members.
C) Posting swallowing precautions at the head of the client's bed: This helps ensure that all staff are aware of the precautions, but it does not promote a broader dialogue about the client's overall care and communication needs.
D) Having interdisciplinary team meetings for the client on a regular basis: This is the correct answer. Regular interdisciplinary meetings encourage collaborative communication, allowing various healthcare professionals to discuss the client’s needs, share observations, and develop a cohesive care plan, which is especially important for clients with communication barriers like expressive aphasia.
Correct Answer is D
Explanation
A) Document assessment findings and interventions after providing care for a group of clients:Delaying documentation until after providing care for a group of clients can lead to incomplete or inaccurate records. Timely documentation is essential for maintaining accurate client records and ensuring continuity of care.
B) Delay cleaning personal work area until the end of the shift:Delaying the cleaning of the personal work area can lead to disorganization and potential safety hazards. Maintaining a clean and organized work area throughout the shift helps improve efficiency and safety.
C) Gather supplies for a client’s dressing change after removing the old dressing:Gathering supplies after removing the old dressing can lead to delays and increased risk of infection. It is more efficient to gather all necessary supplies before starting the procedure to ensure a smooth and timely dressing change.
D) Complete activities for one client before moving to the next client:Completing activities for one client before moving to the next client helps ensure that each client receives focused and uninterrupted care. This approach minimizes the risk of errors and enhances time management by reducing the need to switch tasks frequently.
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