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?
Evaluate uterine tone.
Loosely wrap the cord with petroleum gauze.
Place the client in Trendelenburg position.
Apply fundal pressure.
The Correct Answer is C
A. While evaluating uterine tone is part of routine labor monitoring, it does not address the urgent need to relieve pressure on the prolapsed umbilical cord.
B. Keeping the cord moist is less of a priority than immediate measures to relieve pressure on the cord.
C. For a prolapsed umbilical cord, the immediate goal is to relieve pressure on the cord to maintain fetal oxygenation. Placing the client in the Trendelenburg position or a knee-to-chest position can help reduce the pressure on the cord by using gravity to shift the fetal presenting part toward the diaphragm.
D. Applying fundal pressure is contraindicated in the case of umbilical cord prolapse as it can increase pressure on the cord and exacerbate fetal distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","F","G","I","J"]
Explanation
Yellowing of the eyes could indicate hepatotoxicity, a serious adverse effect associated with some of the anti-tuberculosis medications, particularly rifampin.
Blurred vision could be a sign of optic neuritis, a rare but serious adverse effect associated with ethambutol.
Abdominal pain could indicate hepatitis or hepatotoxicity, which are potential adverse effects of anti-tuberculosis medications like isoniazid and rifampin.
Increased bruising could indicate thrombocytopenia, a serious adverse effect associated with some anti-tuberculosis medications, particularly rifampin.
Increased bleeding tendency could also indicate thrombocytopenia or other hematologic abnormalities.
Red/orange tint to urine could indicate rifampin-induced discoloration of bodily fluids, which is not harmful but can be alarming to patients.
Darkening of urine could also be a result of rifampin-induced discoloration. It's important to differentiate between this harmless side effect and hematuria, which could indicate a more serious issue.
Correct Answer is A
Explanation
A. Uneven shoulder and pelvic heights are classic signs of scoliosis, visible during a physical examination where one shoulder or hip may appear higher than the other.
B. Mild pain in the hip region is not a specific indicator of scoliosis.
C. Exaggerated curvature of the sacrum is not a specific indicator of scoliosis.
D. Limited range-of-motion of the hips is not a specific indicator of scoliosis
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