You do a vaginal examination and you detect a prolapsed cord. Your number one nursing priority would be to:

Place the client in a knee chest position.

Place 8L of 02 by mask, on the patient.

With your hand, during the vaginal exam, keep the fetal head from compressing the cord.

Obtain a consent for an immediate C-Section

Answer and Explanation

The Correct Answer is C

A. While positioning the patient in a knee-chest position may help, the immediate priority is to relieve pressure on the cord.

B. Administering oxygen is important but does not address the primary issue of cord compression.

C. The number one priority in managing a prolapsed cord is to relieve pressure on the cord and prevent fetal hypoxia. The nurse should manually elevate the presenting part of the fetus to reduce cord compression.

D. Obtaining consent for a C-section is important but not the immediate priority in managing a prolapsed cord.

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Correct Answer is ["A","B","E"]

Explanation

A. Monitoring oxygen saturation is important to assess respiratory status, as epiglottitis can cause airway obstruction.

B. Droplet precautions are required for Haemophilus influenzae type B to prevent transmission.

C. Inspecting the epiglottis is contraindicated as it can trigger airway spasm and worsen obstruction.

D. A throat culture is not appropriate in a child with suspected epiglottitis due to the risk of airway obstruction. The diagnosis is typically confirmed through other methods, such as imaging.

E. IV access should be established to provide fluids and medications, especially if the child requires emergency interventions.

A. Tachysystole B. Tachycardia with minimal variability C. Late decelerations with absent variability D. Sinusoidal Pattern E. Absent variability with no periodic changes F. Bradycardia with absent variability G. Late decelerations with moderate variability H. Variable decelerations with absent variability

Correct Answer is ["A","C","D","F"]

Explanation

A. Tachysystole refers to excessive uterine contractions, which can cause fetal distress and indicates a category 3 strip.

B. Tachycardia with minimal variability does not qualify as a category 3 pattern; it is concerning but not as severe as category 3.

C. Late decelerations with absent variability are highly concerning for fetal compromise, making the strip category 3.

D. A sinusoidal pattern indicates severe fetal distress and categorizes the strip as category 3.

E. Absent variability with no periodic changes may suggest a non-reassuring pattern but is not categorized as a category 3 strip unless other signs of fetal distress are present.

F. Bradycardia with absent variability is another critical pattern, indicating poor fetal oxygenation and requiring intervention, categorizing it as a category 3 strip.

G. Late decelerations with moderate variability indicate a category 2 strip, not category 3.

H. Variable decelerations with absent variability can be concerning, but it doesn't automatically classify as category 3 without further complications.

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You do a vaginal examination and you detect a prolapsed cord. Your number one nursing priority would be to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who has epiglottitis due to an infection with Haemophilus influenzae type B. Which of the following actions should the nurse take? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

Select the four criteria below that would indicate a category 3 fetal monitor strip.

Correct Answer is ["A","C","D","F"]

Explanation

When caring for a laboring mother, late decelerations are noted on the fetal heart rate monitor. What actions should the nurse take? (Select all that apply

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You have just completed an inservice on the high risk neonate which responses of the nurses would indicate teaching was successful or teaching needs to be reinforced?

The nurse is giving a lecture on violence against women. The nurse knows teaching needs to be reinforced when a woman states which of the following?

The fetal heart rate decelerates from baseline mirroring the uterine contractions and then returns to baseline by the end of the contraction. What action by the nurse is indicated?