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) “I will need to keep my hand elevated above my heart for several days.”: Elevating the hand above the heart helps reduce swelling and pain after surgery. This practice is crucial for promoting proper healing and minimizing discomfort.
B) “I should expect numbness and tingling in my hand.”: Numbness and tingling are not expected outcomes and could indicate complications. These symptoms should be reported to the healthcare provider for further evaluation.
C) “I should not use my affected hand for 4 to 6 weeks.”: Complete restriction of hand use for 4 to 6 weeks is unnecessary and could lead to stiffness and decreased function. Gradual use and movement are encouraged to aid recovery.
D) “I can apply heat for the first 24 hours to minimize the pain in my hand.”: Applying heat in the first 24 hours can increase swelling and should be avoided. Cold therapy is recommended initially to reduce inflammation and pain.
Correct Answer is C
Explanation
A) Perform exercises prior to bedtime: Engaging in vigorous exercise right before bedtime can actually be stimulating and may interfere with the ability to fall asleep. It is generally recommended to complete exercise earlier in the day to promote better sleep.
B) Stay in bed at least 1 hr if unable to fall asleep: This practice can lead to increased frustration and anxiety about sleep. Instead, it is often advised to get out of bed and engage in a calming activity until feeling sleepy again, which can help reduce sleep anxiety.
C) Eat a light snack before bedtime: Consuming a light snack can be beneficial, as certain foods (like those containing tryptophan) may promote sleepiness. It is important to avoid heavy meals, but a small snack can help some individuals feel more comfortable and ready for sleep.
D) Take a 1-hr nap during the day: While napping can be beneficial, a long nap may interfere with nighttime sleep, especially if taken later in the day. It’s generally better to keep naps short (20-30 minutes) and earlier in the day to avoid impacting nighttime sleep quality.
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