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 B
Explanation
A. Suspiciousness of others is more characteristic of paranoid personality disorder.
B. Preoccupation with aging is a common characteristic of narcissistic personality disorder. Individuals with this disorder often have an exaggerated sense of self- importance, a need for admiration, and a lack of empathy for others. Concerns about aging may stem from a fear of losing their perceived attractiveness or power.
C. Exhibiting separation anxiety is not typically associated with narcissistic personality disorder.
D. Ritualistic behavior may be seen in obsessive-compulsive personality disorder but is not a defining feature of narcissistic personality disorder.
Correct Answer is C
Explanation
A. This type of play usually begins around ages 3 to 4.
B. While possible, this is more typical in slightly older children who engage in more complex forms of pretend play.
C. At 30 months (2.5 years old), children are typically engaged in simple pretend play and enjoy playing with larger, more manipulable toys like plastic trucks. Their motor skills and cognitive development at this stage support this type of play.
D. Coordination for jumping rope generally develops later, closer to school age.
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