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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Excessive sweating is a common adverse effect of sertraline, and it is essential for the nurse to educate the client about this potential side effect to enhance medication adherence and manage expectations.
B. Dry cough is not typically associated with sertraline, and its inclusion in the education may confuse the client and undermine the credibility of the nurse's teaching.
C. Increased urinary frequency is not commonly reported with sertraline use; therefore, including it in the client education may lead to misinformation.
D. A metallic taste in the mouth is not a commonly reported adverse effect of sertraline and should not be included in the client education as it may cause unnecessary concern or confusion.
Correct Answer is D
Explanation
A. Primary glaucoma is not typically considered a contraindication to kidney donation.
B. Amputation, unless associated with significant underlying medical conditions, is not necessarily a contraindication to kidney donation.
C. Osteoarthritis, a degenerative joint disease, is unlikely to be a contraindication to kidney donation unless it significantly affects the donor's overall health.
D. Hypertension is a significant risk factor for kidney disease and can increase the risk of complications for both the donor and the recipient. It is typically considered a contraindication to kidney donation.
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