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
Explanation
A. Basal body temperature should be measured immediately upon waking and before any physical activity to ensure accuracy in detecting the slight temperature rise after ovulation.
B. Temperature taken after getting out of bed may not accurately reflect the basal body temperature.
C. Basal body temperature is best measured in the morning.
D. The timing here still allows for too much activity before measuring temperature, which can affect the reading.
Correct Answer is D
Explanation
A. Changing a dressing on an implanted central venous access device involves a sterile procedure and assessment, requiring the skills and knowledge of a licensed nurse.
B. Removing an NG tube is a task beyond an AP’s scope and requires the specialized skills of a registered nurse.
C. Suctioning a tracheostomy requires specialised training and skill to perform safely and should not be delegated to assistive personnel.
D. Performing postmortem is within the scope of an assistive personnel. It does not require any specialized skills and knowledge of a registered nurse.
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