A nurse is caring for a client who is in labor.

Exhibits

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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A,B,C"},"B":{"answers":"A,B,C"},"C":{"answers":"A,B,C"},"D":{"answers":"A,B"}}

Explanation

Assessment Findings	Sprain	Fracture	Dislocation
Ecchymosis	✅	✅	✅
Pain level	✅	✅	✅
Edema	✅	✅	✅
Sensation	✅	✅

Rationale:

Ecchymosis (bruising):

Sprain: Common due to soft tissue damage.

Fracture: Frequently present due to bone and soft tissue injury.

Dislocation: Bruising often accompanies joint dislocation.

Pain level:

Sprain: Moderate pain, often exacerbated by movement.

Fracture: Pain is typically sharp and worsens with movement or weight-bearing.

Dislocation: Severe pain due to misalignment of the joint.

Edema:

Sprain: Common due to inflammation from ligament injury.

Fracture: Swelling is typical around the fracture site.

Dislocation: Edema occurs due to joint misalignment and tissue trauma.

Sensation (tingling):

Sprain: Nerve compression or irritation may cause tingling.

Fracture: Tingling can result from nerve involvement or swelling near the fracture site.

Dislocation: Tingling is less common unless nerve damage occurs, which is more serious and often leads to numbness or motor impairment.

A. Encourage the client to avoid wearing shoes at home. B. Place a throw rug over electrical cords. C. Ensure that area rugs have rubber backs. D. Mark the edges of the doorway to the house with tape.

Correct Answer is C

Explanation

A. Wearing well-fitted shoes at home helps prevent slips and falls.

B. Placing throw rugs over electrical cords increases the risk of tripping.

C. Area rugs with rubber backs prevent slipping, reducing the risk of falls in a postoperative client.

D. Marking doorways with tape is not necessary for a client after knee replacement and may be more applicable for clients with visual impairments.

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A nurse is caring for a client who is in labor. Exhibits Select the 5 actions the nurse should take.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A,B,C"},"B":{"answers":"A,B,C"},"C":{"answers":"A,B,C"},"D":{"answers":"A,B"}}

Explanation

A nurse is providing teaching about home safety to the adult child of an older adult client who is postoperative following knee replacement surgery. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

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A nurse is caring for a client who is in labor.

Exhibits

Select the 5 actions the nurse should take.