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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","F"]
Explanation
A. This statement is incorrect because tuberculosis treatment typically lasts longer than a week, and the client may remain contagious until the infectiousness subsides, which usually occurs after a few weeks of treatment.
B. TB treatment typically lasts for 6 months, not 6 weeks.
C. Rifampin, one of the medications for tuberculosis, can cause red-orange discoloration of body fluids (including tears, saliva, and urine), and can typically discolor contact lenses.
D. Directly observed therapy (DOT) is a recommended strategy for tuberculosis treatment to ensure medication adherence. Having someone observe the client taking their medication helps to confirm compliance and reduces the risk of non- adherence.
E. This statement is incorrect because alcohol consumption can interact with some tuberculosis medications, leading to potential liver toxicity or reducing the effectiveness of the drugs.
F. This statement demonstrates an understanding of the importance of informing the healthcare provider about any new medications. It's crucial to avoid potential interactions between tuberculosis medications and other drugs.
G. The Mantoux test is typically not repeated during tuberculosis treatment unless there is a specific clinical indication, such as an initial negative test with ongoing symptoms or exposure.
Correct Answer is B
Explanation
A. Coarctation of the aorta typically results in hypertension in the upper extremities due to increased pressure proximal to the coarctation.
B. Weak or absent femoral pulses are characteristic findings in coarctation of the aorta due to reduced blood flow to the lower extremities beyond the coarctation. This finding indicates peripheral vascular compromise in the lower limbs.
C. Frequent nosebleeds are not typically associated with coarctation of the aorta.
D. Coarctation of the aorta does not directly affect intracranial pressure.
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