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 B
Explanation
A. Modern ICDs are designed to withstand interference from household appliances like microwaves.
B. Wearing loose clothing over the implant site can help avoid irritation and discomfort around the ICD.
C. It is recommended to keep cell phones at least six inches away from the ICD to avoid potential electromagnetic interference.
D. There is no general restriction against showering with an ICD; precautions mainly focus on the period immediately after implantation.
Correct Answer is B
Explanation
A. While maintaining eye contact during feedings can foster bonding and comfort, it is not specifically beneficial for managing symptoms of neonatal abstinence syndrome (NAS).
B. Minimizing noise in the newborn's environment is crucial for a baby with NAS. These infants often have increased sensitivity to stimulation and can become easily agitated. A quiet, calming environment can help soothe them.
C. Administering naloxone to a newborn with NAS is not recommended. Naloxone is an opioid antagonist and, while it can reverse opioid effects acutely, it is not a treatment for the withdrawal symptoms associated with NAS.
D. Swaddling the newborn is beneficial, but the legs should not be extended.
Swaddling should allow for some movement of the legs and hips to prevent the development of hip dysplasia. Swaddling in a way that allows the legs to bend and move is generally recommended.
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