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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Acute leukemia can cause thrombocytopenia, which is a decrease in the number of platelets in the blood. Platelets are essential for blood clotting, and a low platelet count can result in heavy menstrual bleeding. Therefore, reviewing the client's platelet count is the priority in response to the client's statement. The other laboratory data may also be important to assess, but platelet count is the most relevant in this situation.
Correct Answer is A
Explanation
One of the most important interventions in caring for clients with major depressive disorder is building a therapeutic relationship. Scheduling regular periods of time for interaction with the client demonstrates support and provides an opportunity for the client to express their feelings and concerns. Journaling and self-reflection can be helpful interventions for some clients, but they do not necessarily demonstrate support.
Assisting the client to identify symptoms of depression is important for assessment and care planning, but it is not a way to demonstrate support.
Incorporating animated communication techniques may be appropriate for certain clients, but it is not a universal intervention for supporting clients with major depressive disorder.
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