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?
Evaluate uterine tone.
Loosely wrap the cord with petroleum gauze.
Place the client in Trendelenburg position.
Apply fundal pressure.
The Correct Answer is C
A. While evaluating uterine tone is part of routine labor monitoring, it does not address the urgent need to relieve pressure on the prolapsed umbilical cord.
B. Keeping the cord moist is less of a priority than immediate measures to relieve pressure on the cord.
C. For a prolapsed umbilical cord, the immediate goal is to relieve pressure on the cord to maintain fetal oxygenation. Placing the client in the Trendelenburg position or a knee-to-chest position can help reduce the pressure on the cord by using gravity to shift the fetal presenting part toward the diaphragm.
D. Applying fundal pressure is contraindicated in the case of umbilical cord prolapse as it can increase pressure on the cord and exacerbate fetal distress.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While physical therapy may be involved in ALS care for mobility and activities of daily living, they are not the priority for addressing dysphagia.
B. Occupational therapy may be involved in ALS care for mobility and activities of daily living, they are not the priority for addressing dysphagia.
C. Dysphagia in amyotrophic lateral sclerosis (ALS) requires collaboration with a speech-language pathologist to assess swallowing function, recommend safe
feeding techniques, and possibly provide swallowing therapy. Ensuring adequate nutrition and preventing aspiration are crucial aspects of care for clients with ALS and dysphagia.
D. Consulting a dietitian is important for nutritional support, but ensuring safe swallowing takes precedence.
Correct Answer is B
Explanation
A. A towel on the floor outside of the shower could be a tripping hazard.
B. This prevents slipping and falls, which is crucial for someone recovering from knee surgery.
C. Slippers with non-slip soles would be a safer choice to prevent falls.
D. While handrails are helpful for mobility and safety, this recommendation does not address the immediate postoperative care needs of the client following knee surgery.
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