A nurse is caring for a client who is in labour and notes that the umbilical cord is prolapsed. Which of the following actions should the nurse take?

Loosely wrap the cord with petroleum gauze.

Place the client in Trendelenburg position.

Evaluate uterine tone.

Apply fundal pressure

Answer and Explanation

The Correct Answer is B

Choice A reason:

Wrapping the cord with petroleum gauze is not recommended. Handling the cord directly can lead to vasospasm and worsen the situation.

Choice B reason:

The Trendelenburg position involves placing the mother with her head lower than her pelvis. This position helps to alleviate pressure on the umbilical cord, reducing the risk of cord compression and compromising blood flow to the baby. Additionally, the nurse should also manually elevate the presenting part of the fetus off the umbilical cord to further relieve pressure. These actions can help mitigate the potential complications associated with umbilical cord prolapse until further medical interventions can be implemented.

Choice C reason:

Evaluate uterine tone. While evaluating uterine tone is an important part of the overall assessment during labour, it is not the priority action in the case of umbilical cord prolapse. The immediate concern is to relieve pressure on the cord.

Choice D reason:

Option D: Apply fundal pressure. Fundal pressure should not be applied during umbilical cord prolapse as it may push the baby's presenting part further onto the cord, worsening the situation.

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Correct Answer is D

Explanation

Option A is incorrect because enrolling the UAP in a hospital education class on conducting safe client care does not address the immediate problem or correct the error.

Option B-This would be inappropriate for oral care in an unconscious client as it increases the risk of aspiration.The side-lying position is safer for oral hygiene in unconscious clients.

Option C:While encouraging family participation can be beneficial, it is not the most immediate concern in this situation. The priority is ensuring safe and effective care, which the UAP is providing correctly.

Option D:The flat side-lying position is appropriate for an unconscious client during oral hygiene care. This position helps to prevent aspiration by allowing any secretions or fluids to drain out of the mouth rather than down the throat, which could happen if the client were in a Fowler's position. The presence of the emesis basin near the chin also indicates that the UAP is prepared to catch any fluids, further reducing the risk of aspiration

A. A client forgets to buy their partner a birthday gift after a disagreement. B. A client who was abused as a child describes the abuse as if it happened to someone else. C. A client who is shorter than average is verbally assertive with coworkers. D. A client states that they did not get a job promotion because the boss did not like them.

Correct Answer is B

Explanation

A. This choice is incorrect because forgetting to buy a gift is not an example of dissociation, but rather a sign of poor memory or lack of attention.

B. This choice is correct because describing the abuse as if it happened to someone else is an example of dissociation, which is a defense mechanism that involves separating oneself from painful or traumatic experiences.

C. This choice is incorrect because being verbally assertive is not an example of dissociation, but rather a personality trait or a coping skill.

D. This choice is incorrect because blaming the boss for not getting a promotion is not an example of dissociation, but rather a sign of external locus of control or rationalization.

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A nurse is caring for a client who is in labour and notes that the umbilical cord is prolapsed. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) observes an unlicensed assistive personnel (UAP) performing oral hygiene on an unconscious client who is lying in a ﬂat side-lying position with an emesis basin on the bedside table near the chin. Which action should the PN take?

Correct Answer is D

Explanation

A nurse at a mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is using dissociation as a defense mechanism?

Correct Answer is B

Explanation

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