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 C

Explanation

A. February 1 is not the correct EDB according to Nägele's rule. Nägele's rule states that to estimate the EDB, subtract three months from the LMP and add seven days and one year. Therefore, May 8 minus three months is February 8, plus seven days is February 15, plus one year is February 15 of the following year.

B. February 8 is not the correct EDB according to Nägele's rule. Nägele's rule states that to estimate the EDB, subtract three months from the LMP and add seven days and one year. Therefore, May 8 minus three months is February 8, plus seven days is February 15, minus seven days is February 8, plus one year is February 8 of the following year.

C. February 15 is the correct EDB according to Nägele's rule. Nägele's rule states that to estimate the EDB, subtract three months from the LMP and add seven days and one year. Therefore, May 8 minus three months is February 8, plus seven days is February 15, plus one year is February 15 of the following year.

D. February 22 is not the correct EDB according to Nägele's rule. Nägele's rule states that to estimate the EDB, subtract three months from the LMP and add seven days and one year. Therefore, May 8 minus three months is February 8, plus seven days is February 15, plus seven days is February 22, plus one year is February 22 of the following year.

A. Massage bony prominences on the client's left side. B. Support the client's left arm on a pillow while sitting. C. Position the bedside table on the client's left side. D. Place the client's cane on their left side while ambulating.

Correct Answer is B

Explanation

A is incorrect because massaging bony prominences on the client's left side can increase the risk of skin breakdown and pressure ulcers. The nurse should avoid applying pressure to areas with impaired circulation or sensation.

B is correct because supporting the client's left arm on a pillow while sitting can prevent edema, contractures, and nerve damage. The nurse should also encourage the client to perform active and passive range of motion exercises on their left arm.

C is incorrect because positioning the bedside table on the client's left side can discourage the client from using their right side, which can lead to neglect and learned nonuse. The nurse should position the bedside table on the client's right side and encourage them to reach for items with their right hand.

D is incorrect because placing the client's cane on their left side while ambulating can cause instability and falls. The nurse should place the cane on the client's right side and instruct them to move their left leg and cane together, followed by their right leg.

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