The practical nurse (PN) is assigned to assist in the care of a laboring client at 42-weeks gestation. While providing perineal care, the PN observes the umbilical cord protruding from the vagina. Which action should the PN take?
Support the client's upper body and knees with pillows.
Encourage the client to push with the next contraction.
Assist the team to prepare for a possible cesarean delivery.
Gently wrap the cord with a dry sterile dressing.
The Correct Answer is C
The umbilical cord prolapse is an emergency situation that requires immediate intervention. The PN should not attempt to push the cord back into the vagina or cover it with a dry sterile dressing. Instead, the PN should notify the healthcare provider and the obstetrical team and assist in preparing for an emergency cesarean delivery.
Option A and B may be appropriate in some situations, but they are not the priority in this scenario.
Therefore, options A, B, and D are not answers because they do not address the immediate emergency of umbilical cord prolapse.
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Related Questions
Correct Answer is C
Explanation
The umbilical cord prolapse is an emergency situation that requires immediate intervention. The PN should not attempt to push the cord back into the vagina or cover it with a dry sterile dressing. Instead, the PN should notify the healthcare provider and the obstetrical team and assist in preparing for an emergency cesarean delivery.
Option A and B may be appropriate in some situations, but they are not the priority in this scenario.
Therefore, options A, B, and D are not answers because they do not address the immediate emergency of umbilical cord prolapse.
Correct Answer is B
Explanation
If the client in active labor expresses a desire to empty her bladder and her vaginal exam is unchanged, the practical nurse (PN) should assist her up to the bathroom. An empty bladder can help facilitate labor progress.
Reviewing the fetal heart rate pattern (A) is important, but it is not the most appropriate action in response to the client's request to empty her bladder. Checking the perineum for changes in "show" or discharge (C) is also important, but it is not the most appropriate action in this situation. Obtaining a straight catheter kit to empty the client's bladder (D) may be necessary if she is unable to empty her bladder on her own, but assisting her up to the bathroom should be attempted first.
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