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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Eating a meal before postural drainage could increase the risk of aspiration during the procedure.
B. Completing oral hygiene is good practice but not directly related to postural drainage.
C. Albuterol can help open the airways, making the postural drainage process more effective.
D. Pancrelipase is a medication to aid in digestion and is not directly related to the initiation of postural drainage.

A. "This type of seizure lasts 30 to 60 seconds." B. "The child usually has an aura prior to onset." C. "This type of seizure can be mistaken for daydreaming." D. "This type of seizure has a gradual onset."

Correct Answer is C

Explanation

A. Absence seizures typically last only a few seconds, not as long as 30 to 60 seconds, so this statement is incorrect.
B. Absence seizures typically occur without warning or aura, so this statement is incorrect.
C. Absence seizures often manifest as brief episodes of staring or blank expression, which can be mistaken for daydreaming or inattention. Educating parents about this characteristic helps them recognize and appropriately respond to absence seizures in their child.
D. Absence seizures have a sudden onset and offset without warning, so this statement is incorrect.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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