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 A
Explanation
Choice A reason:
Acetaminophen is a safer choice for pain relief in clients with cholelithiasis because it does not have significant effects on the gallbladder or biliary system. It can provide effective pain relief without exacerbating the underlying condition.
Choice B reason:
Omeprazole Omeprazole should not administer because it is a proton pump inhibitor (PPI) used to reduce stomach acid production and treat conditions such as gastroesophageal reflux disease (GERD) and peptic ulcers. It is not indicated for the treatment of pain and discomfort associated with cholelithiasis.
Choice C reason
Should not be administered
Metoclopramide Metoclopramide should not be administered because it is a medication used to treat gastrointestinal issues such as nausea, vomiting, and gastroparesis. It is not indicated for the treatment of pain associated with cholelithiasis.
Choice D reason:
Ketorolac Ketorolac should not be administered because it is an NSAID used for moderate to severe pain. However, it should be avoided in clients with cholelithiasis due to its potential adverse effects on the gallbladder and biliary system.
Correct Answer is A
Explanation
A. A client who has cellulitis and is receiving oral antibiotics every 8 hr has a mild to moderate infection that can be managed at home with proper wound care and medication adherence. The client does not require hospitalization unless there are signs of systemic infection or complications.
B. A client who is postoperative following an upper endoscopy procedure and is alert but does not have a gag reflex has a high risk of aspiration and airway obstruction due to impaired swallowing function. The client requires close monitoring and intervention until the gag reflex returns, which can take several hours or longer depending on the type and amount of anesthesia used.
C. A mother and their newborn 12 hr postdelivery have not completed the minimum recommended stay of 24 to 48 hours for uncomplicated vaginal deliveries or 72 to 96 hours for cesarean deliveries, according to the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. The mother and their newborn require assessment, education, support, and follow-up care to ensure their health and well-being.
D. A client who has lower extremity weakness and is newly admitted for observation has an undiagnosed condition that could indicate a serious neurological or vascular problem, such as stroke, spinal cord injury, or peripheral artery disease. The client requires diagnostic testing, evaluation, treatment, and rehabilitation to prevent further deterioration or complications.
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