A nurse is caring for a client who is in labor.
Select the 5 actions the nurse should take.
Exert upward pressure on the presenting part.
Place the client in a Trendelenburg position.
Administer oxygen at 10 L/min via nonrebreather face mask.
Attempt to push the umbilical cord back into the cervix.
Have the charge nurse notify the provider.
Increase the flow rate of the maintenance IV fluid.
Correct Answer : A,B,C,E,F
A. Exert upward pressure on the presenting part. If there are signs of cord prolapse or pressure on the umbilical cord, exerting upward pressure on the presenting part can relieve compression. This action helps maintain blood flow and oxygen supply to the fetus.
B. Place the client in a Trendelenburg position. Positioning the client with the pelvis elevated higher than the head can reduce pressure on the umbilical cord if prolapse is suspected or confirmed. This promotes fetal circulation and decreases the risk of hypoxia.
C. Administer oxygen at 10 L/min via nonrebreather face mask. Administering high-flow oxygen increases maternal oxygenation, which in turn improves oxygen delivery to the fetus. This is a priority intervention to ensure fetal well-being during labor.
D. Attempt to push the umbilical cord back into the cervix. This is incorrect because pushing the cord back into the cervix is contraindicated due to the risk of damaging the cord or introducing infection. Other measures, such as repositioning and elevating the presenting part, should be prioritized instead.
E. Have the charge nurse notify the provider. Timely communication with the provider is critical when complications arise during labor, such as suspected umbilical cord prolapse. The provider may need to intervene urgently, possibly requiring an emergency cesarean section.
F. Increase the flow rate of the maintenance IV fluid. Increasing the IV fluid rate helps improve maternal circulation and blood flow to the uterus and placenta, ensuring the fetus receives adequate oxygen and nutrients. This is a supportive measure during labor when complications arise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Flumazenil is used for benzodiazepine overdose, not opioid overdose.
B. Naloxone is the antidote for opioid overdose and is indicated here due to the low respiratory rate and recent administration of hydromorphone.
C. Acetylcysteine is used for acetaminophen overdose, not opioids.
D. Protamine is used to reverse heparin, not opioids.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"}}
Explanation
|
Potential action |
Indicated |
Contraindicated |
|
Ask the client about the content of their hallucinations. |
✓ |
|
|
Instruct the client on expected hygiene practices. |
✓ |
|
|
Allow the client to watch TV at a high volume. |
✓ |
|
|
Assess the client for suicidal ideation. |
✓ |
|
|
Place the client in a room near the activity |
✓ |
Rationale
- Ask the client about the content of their hallucinations: Indicated
- Understanding the content of hallucinations can help in assessing the severity and nature of the client's condition, and in planning appropriate interventions.
- Instruct the client on expected hygiene practices: Indicated
- Encouraging and educating the client about personal hygiene is important for their overall well-being and social interactions.
- Allow the client to watch TV at a high volume: Contraindicated
- High volume and excessive stimulation can exacerbate symptoms of schizophrenia, such as hallucinations and agitation.
- Assess the client for suicidal ideation: Indicated
- Regular assessment for suicidal thoughts is crucial, even if the client initially denies them, as their mental state can change.
- Place the client in a room near the activity: Contraindicated
- A quieter environment is generally more beneficial for clients with schizophrenia to reduce overstimulation and stress.
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