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 C
Explanation
The practical nurse should report to the charge nurse that the client is near delivery, as the client's signs indicate that she is in the transition phase of labor and is likely to deliver soon. The PN should also assess the client's vital signs, fetal heart rate, and pain level, and prepare the delivery equipment.
The husband can be asked to provide emotional support to the client during labor.
The rapid response team may be called in case of a medical emergency, but this is not indicated based on the information given.
Checking the time, the last PRN narcotic analgesic was given is also not indicated at this point, as the client is close to delivery and may not have time for medication to take effect.
Correct Answer is A
Explanation
If the practical nurse (PN) is caring for a client who delivered 6 hours ago and assessment findings reveal a boggy uterus that is displaced above and to the right of the umbilicus, the PN should encourage the client to void. A full bladder can displace the uterus and prevent it from contracting properly, leading to a boggy uterus. Encouraging the client to void can help empty the bladder and allow the uterus to contract and return to its normal position. The other actions listed may also be appropriate in some situations, but encouraging voiding is the most appropriate action in this situation.
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