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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
A. Postpartum hemorrhage is incorrect because the client has scant lochia rubra and a firm fundus at the umbilicus, which indicate normal uterine involution and bleeding.
B. Seizures is correct because the client has signs of severe preeclampsia, such as headache, blurred vision, nausea, hyperreflexia, and clonus. These are indications of increased intracranial pressure and cerebral edema, which can lead to seizures or eclampsia.
C. Hyperglycemia is incorrect because there is no evidence of diabetes mellitus or gestational diabetes in the client's history or findings.
D. Hypoxemia is incorrect because there is no evidence of respiratory distress or impaired gas exchange in the client's history or findings.
E. Infection is incorrect because the client has no signs of infection, such as fever, malaise, foul-smelling lochia, or elevated WBC count.
Correct Answer is B
Explanation
A. Incorrect. Measuring the group's work against the assigned objectives is a task role that belongs to the evaluator, who assesses the quality and effectiveness of the group's performance.
B. Correct. Noting the progress of the group toward assigned goals is a task role that belongs to the orienteer, who keeps track of where the group is heading and summarizes what has been accomplished.
C. Incorrect. Sharing experiences as an authority figure is a task role that belongs to the information giver, who provides factual data or personal knowledge to the group.
D. Incorrect. Offering new and fresh ideas on an issue is a task role that belongs to the initiator, who proposes new solutions or approaches to problems.
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