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 A
Explanation
The practical nurse (PN) should obtain information about the client's current medications, including any analgesics or antianxiety medications that may be contributing to the confusion. These medications can cause cognitive impairment and confusion, especially in older adults. It is important to assess the client's mental status and identify any potential causes of confusion, as this can indicate a change in the client's condition that requires further evaluation and intervention.
Option B is incorrect as it refers to a history of situational depression, which may not be relevant to the current situation.
Option C is also incorrect as it refers to previous falls, which may not be related to the current confusion.
Option D is incorrect as it refers to the client's history of alcohol abuse, which may be important to know but is not the most relevant information to obtain in this situation.
Correct Answer is D
Explanation
The first intervention the PN should implement is to **sit and offer to listen to the client's concerns**. It is important to approach the client in a calm and non-threatening manner and to establish a rapport with him. Offering to listen to his concerns can help the client feel heard and understood, and can help build trust between the client and the PN.
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