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.

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Correct Answer is B

Explanation

A) "Decrease the ventilator flow rate.": Lowering the flow rate may not address the underlying issue causing the high-pressure alarm and could potentially worsen the client's respiratory distress. It is essential to identify and manage the cause first.

B) "Deliver breaths manually with a resuscitation bag.": This is the most appropriate immediate action. Manually providing breaths ensures the client receives adequate ventilation while the nurse assesses the situation. This intervention prioritizes the client's safety and oxygenation during respiratory distress.

C) "Assess for disconnected tubing.": While checking for disconnected tubing is an important step in troubleshooting the alarm, it may take time to assess and does not provide immediate support to the client in respiratory distress. Ensuring adequate ventilation is the priority.

D) "Reevaluate the client for an ET cuff leak.": Evaluating for an ET cuff leak is relevant but is not the most urgent action in this situation. The high-pressure alarm indicates an immediate problem that requires rapid intervention, such as manual ventilation, to stabilize the client.

A. Monitor the child's cardiac status. B. Administer antibiotics via intermittent IV bolus for 24 hr. C. Give scheduled doses of acetaminophen every hr. D. Provide stimulation with children of the same age in the play room.

Correct Answer is A

Explanation

A) Monitoring the child's cardiac status is crucial in the acute phase of Kawasaki disease, as the disease can lead to complications such as myocarditis and coronary artery aneurysms. Regular assessment of heart rate, blood pressure, and any signs of heart failure is essential for early detection and intervention.

B) Antibiotics are not routinely administered for Kawasaki disease unless there is a concurrent bacterial infection. The primary treatment includes high-dose aspirin and intravenous immunoglobulin (IVIG) to reduce inflammation and prevent cardiac complications.

C) While acetaminophen can be used to manage fever and discomfort, giving it every hour is not appropriate. Scheduled doses should follow dosing guidelines to avoid toxicity and manage the child's symptoms effectively.

D) During the acute phase, children with Kawasaki disease may experience irritability and require rest. Providing stimulation with peers in the playroom may be inappropriate due to the need for reduced activity and rest, making this intervention less suitable.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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