A nurse is caring for a client who is in labor and notes that the umbilical cord is prolapsed. Which of the following actions should the nurse take?
Place the client in Trendelenburg position.
Apply fundal pressure.
Loosely wrap the cord with petroleum gauze.
Evaluate uterine ton
The Correct Answer is A
A. Place the client in Trendelenburg position: This position helps relieve pressure on the umbilical cord, potentially improving blood flow to the fetus. It is an appropriate immediate intervention for a prolapsed cord.
B. Apply fundal pressure: This is contraindicated in cases of cord prolapse as it can exacerbate the situation by pushing the presenting part further down and increasing pressure on the cord.
C. Loosely wrap the cord with petroleum gauze: While protecting the cord is important, simply wrapping it does not address the immediate need to relieve pressure and restore blood flow to the fetus.
D. Evaluate uterine tone: While assessing uterine tone is important during labor, the immediate priority when a prolapsed cord is noted is to relieve pressure on the cord to prevent fetal compromise. Therefore, this step should not be the first action taken.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Assault:Assault refers to an intentional act that creates a reasonable apprehension of imminent harmful or offensive contact. In this scenario, the newly licensed nurse’s statement about inserting a urinary catheter if the client does not void can be perceived as a threat, causing the client to fear an unwanted procedure.
B) Libel:Libel involves making false, defamatory statements in written form that harm someone’s reputation. This option is not applicable in this context, as the nurse’s statement was verbal and did not involve written defamation.
C) Negligence:Negligence occurs when a healthcare provider fails to meet the standard of care, resulting in harm to the client. While the nurse’s statement may be inappropriate, it does not constitute negligence, as it does not involve a breach of the standard of care leading to harm.
D) Battery:Battery involves intentional physical contact with another person without their consent. In this case, the nurse has not yet performed any physical act, so battery has not occurred. The threat alone constitutes assault, not battery.
Correct Answer is A,B,C,D
Explanation
To delegate tasks to assistive personnel (APs) effectively, the nurse should follow this sequence:
- A. Review the skill level and qualifications of each AP.
- B. Communicate appropriate tasks to the APs with specific expectations.
- C. Monitor progress of task completion with each AP.
- D. Evaluate the APs' performance of each task.
This order ensures that the nurse first assesses the abilities of the APs, then clearly communicates tasks, monitors their progress, and finally evaluates their performance.
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