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
Vitamin tablets are unlikely to cause significant harm to the esophagus if the child vomits after ingesting them. However, toilet bowl cleaner and kerosene are corrosive substances that can cause serious damage to the esophagus and other tissues if ingested.
An unknown substance cannot be evaluated for potential harm to the esophagus.
In any case, the mother should be advised to seek immediate medical attention for her child if they have ingested any potentially harmful substance.
The PN should also follow their facility's policies and procedures for managing cases of poisoning or suspected poisoning.
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.
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