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.
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Related Questions
Correct Answer is D
Explanation
A) Acetaminophen: While acetaminophen can be effective for mild to moderate pain relief, it may not be the most appropriate choice for abdominal pain associated with cholelithiasis. Opioids or nonsteroidal anti-inflammatory drugs (NSAIDs) like ketorolac are typically more effective for this type of pain.
B) Omeprazole: This medication is a proton pump inhibitor used primarily for reducing gastric acid secretion and is not indicated for pain management. It does not address the pain caused by cholelithiasis.
C) Metoclopramide: This medication is an antiemetic and prokinetic agent that may help with nausea and vomiting, but it does not directly alleviate pain. It would not be the first choice for pain management in this situation.
D) Ketorolac: This NSAID is effective for managing moderate to severe pain and is suitable for the type of pain associated with cholelithiasis. It has anti-inflammatory properties that can provide significant relief, making it the best option for the client's current symptoms.
Correct Answer is D
Explanation
D. "The estimated blood loss was 250 milliliters":
This is the most appropriate information to include in the hand-off report. The estimated blood loss (EBL) is a key piece of post-operative information that can help guide nursing care, including monitoring for signs of hypovolemia or shock, and assessing for the need for interventions like fluid resuscitation or blood transfusion. It's clinically relevant and helps the nurse on the medical-surgical unit understand the client's post-operative status and needs.
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