A nurse is caring for a client in active labor when the fetal heart monitor indicates a sudden deceleration.
Upon assessment, the nurse notes that the umbilical cord is protruding from the vaginal opening.
The nurse immediately calls for assistance and uses a sterile gloved hand to lift the presenting part off of the cord.
The nurse positions the client in a knee to chest position to relieve pressure on the cord.
Fetal heart tones are monitored continuously.
The provider is notified while preparations for an emergency cesarean birth are initiated.
The nurse documents the time of cord prolapse, interventions, and the client response.
Select the portions of the text that indicate priority nursing actions in response to a prolapsed umbilical cord.
The nurse immediately calls for assistance and uses a sterile gloved hand to lift the presenting part off of the cord.
The nurse positions the client in a knee to chest position to relieve pressure on the cord.
Fetal heart tones are monitored continuously.
The provider is notified while preparations for an emergency cesarean birth are initiated.
Correct Answer : A,B,D
Choice A rationale
This action is critical because immediate manual elevation of the fetal presenting part off the prolapsed umbilical cord directly alleviates cord compression, which is the primary cause of fetal hypoxia and acidosis. Sustained compression compromises umbilical blood flow, depriving the fetus of oxygen and nutrients, leading to severe bradycardia and potential neurological damage. This direct intervention aims to restore uteroplacental perfusion.
Choice B rationale
The knee-to-chest position, along with Trendelenburg or modified Sims, leverages gravity to displace the presenting fetal part away from the pelvis and the prolapsed cord. This physical repositioning reduces the pressure exerted by the fetus on the cord, thereby minimizing further compromise of blood flow and maintaining fetal oxygenation. These positions help to prevent further compression.
Choice C rationale
Continuous fetal heart tone monitoring is essential for ongoing assessment of fetal well-being, but it is not a *priority action* in the sense of directly intervening to relieve cord compression. While crucial for evaluating the effectiveness of interventions and guiding subsequent management, the immediate physical actions to relieve pressure take precedence to mitigate acute fetal distress. Normal fetal heart rate is 110-160 beats per minute.
Choice D rationale
Prompt notification of the provider and initiation of preparations for an emergency cesarean birth are paramount because a prolapsed cord often necessitates immediate delivery to prevent prolonged fetal compromise. This action mobilizes the medical team and resources required for rapid surgical intervention, which is the definitive treatment to resolve the life-threatening situation for the fetus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Scabies typically presents as intensely pruritic papules, vesicles, and burrows, rather than non-pruritic blisters. The characteristic itch is often worse at night and is caused by the mite’s burrowing and excretions under the skin, leading to a hypersensitivity reaction, and does not typically resolve with crusting within 7 days.
Choice B rationale
Prophylactic treatment for household members and close contacts is highly recommended to prevent re-infestation and control the spread of scabies. Even asymptomatic contacts can harbor mites and transmit the infection, making simultaneous treatment crucial for effective eradication and breaking the transmission cycle.
Choice C rationale
Scabies eggs typically hatch within 3 to 4 days after being laid by the female mite in the stratum corneum. The entire life cycle, from egg to adult, takes approximately 10 to 17 days. A 30-day incubation period for eggs is inaccurate and significantly longer than the actual biological process.
Choice D rationale
Scabies is caused by the microscopic mite *Sarcoptes scabiei* var. *hominis*, which burrows into the superficial layers of the epidermis. The female mite deposits eggs and feces within these burrows, leading to an intensely itchy hypersensitivity reaction in the host. This direct infestation causes the characteristic symptoms.
Correct Answer is ["B","D","E"]
Explanation
Choice A rationale
While hearing loss can occur in some individuals with spina bifida due to associated anomalies or complications like meningitis, it is not as universally expected as other neurological impairments. The primary impact of hydrocephalus and neurological damage often manifests in areas directly related to brain development and function, making hearing loss a less common direct consequence.
Choice B rationale
Neurological damage associated with hydrocephalus and spina bifida frequently affects brain regions responsible for speech production and language processing. This can lead to various speech problems, including dysarthria or apraxia of speech, due to impaired motor control or cognitive deficits impacting linguistic expression and comprehension.
Choice C rationale
Frequent seizures are a potential complication of hydrocephalus and neurological damage due to abnormal electrical activity in the brain caused by structural anomalies or increased intracranial pressure. However, while possible, they are not as universally present in all cases as other common motor and cognitive impairments, making them a less frequent expectation.
Choice D rationale
Spina bifida often involves malformations of the spinal cord, directly impacting nerve function to the lower extremities. Hydrocephalus, by causing increased intracranial pressure and brain damage, can further impair motor control pathways. This combination frequently leads to motor deficits, resulting in varying degrees of difficulty walking or complete paralysis.
Choice E rationale
Hydrocephalus, especially when associated with neurological damage, can significantly impair cognitive development due to increased intracranial pressure and damage to brain tissue. This can manifest as delays in various cognitive domains, including learning, memory, problem-solving, and executive functions, impacting overall intellectual functioning.
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