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) This statement demonstrates an understanding of infection prevention related to chickenpox. The contagious period for chickenpox is typically considered to end once the sores have crusted over, making it safe to visit a person who has had chickenpox after this time. This reflects appropriate awareness of infectious disease protocols.
B) This statement reflects a misunderstanding about antibiotic use, as antibiotics are ineffective against viral infections. Taking antibiotics when they are not needed can lead to antibiotic resistance and other complications, highlighting the importance of understanding when to use these medications.
C) Washing hands for only 10 seconds, even with hot water, is insufficient for effective hand hygiene. The Centers for Disease Control and Prevention (CDC) recommends washing hands for at least 20 seconds to effectively remove pathogens, especially after gardening, which can introduce soilborne pathogens.
D) Cleaning a cat's litter box during pregnancy poses a risk for toxoplasmosis, a parasitic infection that can have serious consequences for the fetus. Pregnant women are advised to avoid this task or take precautions if they must do it, demonstrating a lack of understanding of specific infection risks associated with pregnancy.
Correct Answer is A
Explanation
A) The anterior fontanel is open: This is an expected finding in an 8-month-old infant. The anterior fontanel typically remains open until around 12 to 18 months of age, allowing for brain growth.
B) Both fontanels show molding: Molding is usually a temporary shape change of the skull that occurs during birth, particularly in relation to the birth canal. By 8 months, the fontanels should not show molding.
C) Both fontanels are the same size: The anterior fontanel is generally larger than the posterior fontanel. The posterior fontanel typically closes by 2 to 3 months of age and is much smaller.
D) The posterior fontanel is open: This finding is not expected, as the posterior fontanel should have closed by 2 to 3 months of age. An open posterior fontanel at 8 months could indicate a developmental concern.
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