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 C
Explanation
A. "That can't be true. The only voices in this room are yours and mine.": This response dismisses the client’s experience and can invalidate their feelings, which is not therapeutic or supportive.
B. "Do you recognize the voices as belonging to anyone you know?": While this question could gather more information, it might divert the focus from the client’s immediate feelings of fear and distress.
C. "I understand the voices are frightening you, but I do not hear any voices.": This response validates the client's experience of fear and acknowledges their distress while also gently indicating that the nurse does not perceive the voices. It encourages open communication about the client’s feelings.
D. "You shouldn't be afraid when you think the voices are telling you to hurt yourself.": This response is inappropriate as it minimizes the client’s feelings and does not address the seriousness of their statements about self-harm. It’s crucial to acknowledge their fear rather than dismissing it.
Correct Answer is A
Explanation
A. "Offer to take pictures of the newborn for the client.": This is a compassionate and supportive action. Offering to take pictures can help the parents create memories and can be an important part of the grieving process, allowing them to acknowledge their loss.
B. "Assure the client that she can have additional children.": While this may be intended to provide comfort, it can minimize the current loss and may not be what the client needs to hear in the moment. It’s important to validate their feelings of grief first.
C. "Avoid talking to the client about the newborn.": Avoiding the topic can make the client feel isolated in their grief. Open discussions about the newborn can help the parents process their emotions and acknowledge their loss.
D. "Discourage the client from allowing friends to see the newborn.": This is not supportive. Allowing friends and family to see the newborn can provide comfort and support to the grieving parents, and should not be discouraged unless there are specific concerns about health or safety.
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