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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Have the child take a tub bath each morning:Warm tub baths can help alleviate morning stiffness and improve joint mobility in children with juvenile idiopathic arthritis. This intervention can be soothing and help the child start the day with less discomfort, promoting better overall function and quality of life.
B) Encourage the child to take naps during the day:While rest is important, excessive napping can lead to decreased physical activity, which may worsen joint stiffness and reduce muscle strength. It is more beneficial to encourage regular, gentle exercise and activity throughout the day.
C) Apply splints to the child’s extremities during the day:Splints are typically used at night to prevent joint deformities and maintain proper alignment. During the day, it is important for the child to remain active and use their joints to maintain mobility and strength.
D) Keep the child on bedrest as long as pain persists:Prolonged bedrest can lead to muscle atrophy and joint stiffness, which can worsen the child’s condition. Encouraging gentle movement and activity, even when experiencing pain, is crucial for managing juvenile idiopathic arthritis effectively.
Correct Answer is B
Explanation
A) The statement about returning to school once the fever has subsided is not sufficient for varicella. Children should not return until the lesions have crusted over to prevent spreading the infection.
B) The recommendation that the child can return to school once the lesions have crusted over is accurate. Varicella is contagious from 1 to 2 days before the rash appears until all lesions have crusted over, which usually occurs about 6 days after the onset of the rash.
C) A negative titer result is not necessary for a child to return to school. Immunity can be confirmed through vaccination history or prior infection; thus, this statement is misleading.
D) Since varicella is a viral infection, antibiotics are not indicated for treatment. Therefore, stating that the child can return to school 24 hours after beginning antibiotics is incorrect and could lead to misunderstanding about the management of the illness.
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