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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A) Using up to 40 nicotine lozenges per day is excessive. The typical recommendation is to limit the use of nicotine lozenges to 5-6 per day, as excessive use can lead to nicotine toxicity and increased withdrawal symptoms.

B) Substituting tobacco use with an electronic cigarette is not recommended as a treatment option. While e-cigarettes may reduce exposure to some harmful substances found in traditional tobacco products, they can still maintain nicotine addiction and are not a clinically approved smoking cessation method.

C) Limiting the use of nicotine gum to 6 months is appropriate. While nicotine replacement therapies can be helpful for managing withdrawal symptoms, prolonged use beyond 6 months may not be beneficial and can maintain dependence on nicotine.

D) Using progressively larger nicotine patches is not the recommended approach. Nicotine patches should typically be started at a prescribed dose based on the client's previous nicotine use and adjusted as necessary, rather than increasing the dose without proper guidance.

A. Provide the client with a 4g sodium diet. B. Ambulate the client every 4 hr while awake. C. Infuse 0.9% sodium chloride 500 mL IV bolus over 1 hr. D. Administer enalapril 2.5 mg PO twice daily.

Correct Answer is D

Explanation

A) Provide the client with a 4g sodium diet: This is incorrect. Clients with acute heart failure typically require a low-sodium diet (often less than 2g per day) to help manage fluid retention and reduce workload on the heart.

B) Ambulate the client every 4 hr while awake: While mobility is important, the frequency and timing of ambulation in clients with acute heart failure should be carefully considered based on their stability and fatigue level. It may not be appropriate to ambulate every 4 hours.

C) Infuse 0.9% sodium chloride 500 mL IV bolus over 1 hr: This is generally not appropriate for clients with acute heart failure due to the risk of fluid overload. Instead, fluid management often involves restricting IV fluids and closely monitoring fluid balance.

D) Administer enalapril 2.5 mg PO twice daily: This prescription is appropriate. Enalapril, an ACE inhibitor, is commonly used to manage heart failure by reducing afterload and improving cardiac output. It helps alleviate symptoms and improve quality of life in heart failure patients.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is discussing treatment options with a client who is experiencing nicotine withdrawal. Which of the following information should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is admitting a client who has acute heart failure. Which of the following prescriptions from the provider should the nurse anticipate?

Correct Answer is D

Explanation

A nurse has identified tasks to delegate to a group of assistive personnel (AP) after receiving change-of-shift report. Identify the sequence of steps the nurse should follow when delegating tasks to the APs. (Move the steps, placing them in the selected order of performance. Use all the steps.)

A nurse is teaching the parents of a school-age child who is newly diagnosed with juvenile idiopathic arthritis. Which of the following interventions should the nurse include in the teaching?

A nurse is caring for a client who speaks a different language than the nurse and is using an interpreter. Which of the following actions should the nurse take when working with the interpreter?

A nurse manager on an interprofessional team is creating a disaster plan. The nurse should include in the plan that which of the following actions is the responsibility of the unit nurse during a disaster?

A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include?

A nurse is updating the plan of care for a client who has amyotrophic lateral sclerosis with dysphagia. Which of the following interprofessional team members should the nurse identify as the priority to consult?

A nurse is planning to administer vancomycin IV to a client. Which of the following actions should the nurse take to reduce the risk of an adverse reaction to the vancomycin?

A nurse is caring for a client who has systemic lupus erythematosus. Which of the following client findings should the nurse expect?