A nurse is caring for a client who is in labour and notes that the umbilical cord is prolapsed. Which of the following actions should the nurse take?

Loosely wrap the cord with petroleum gauze.

Place the client in Trendelenburg position.

Evaluate uterine tone.

Apply fundal pressure

Answer and Explanation

The Correct Answer is B

Choice A reason:

Wrapping the cord with petroleum gauze is not recommended. Handling the cord directly can lead to vasospasm and worsen the situation.

Choice B reason:

The Trendelenburg position involves placing the mother with her head lower than her pelvis. This position helps to alleviate pressure on the umbilical cord, reducing the risk of cord compression and compromising blood flow to the baby. Additionally, the nurse should also manually elevate the presenting part of the fetus off the umbilical cord to further relieve pressure. These actions can help mitigate the potential complications associated with umbilical cord prolapse until further medical interventions can be implemented.

Choice C reason:

Evaluate uterine tone. While evaluating uterine tone is an important part of the overall assessment during labour, it is not the priority action in the case of umbilical cord prolapse. The immediate concern is to relieve pressure on the cord.

Choice D reason:

Option D: Apply fundal pressure. Fundal pressure should not be applied during umbilical cord prolapse as it may push the baby's presenting part further onto the cord, worsening the situation.

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Correct Answer is ["13"]

Explanation

gtt/min = (mL/hr x gtt/mL) / 60

Plugging in the given values, we get:

gtt/min = (50 x 15) / 60

gtt/min = 750 / 60

gtt/min = 12.5

Rounding to the nearest whole number, the answer is 13.

A. "We can expect the hospice nurse to provide support for us after our mother's death." B. "A hospice nurse will come to the house each time our mother needs pain medication." C. "Now that my mother is receiving hospice services, we will not be able to get respite care." D. "Hospice care focuses on arranging treatment that will prolong our mother's life."

Correct Answer is A

Explanation

A is correct because hospice care includes bereavement support for the family for up to a year after the client's death.

B is incorrect because the hospice nurse does not administer pain medication, but rather teaches the family how to manage the client's pain at home.

C is incorrect because respite care is one of the services that hospice provides to allow the family to take a break from caregiving.

D is incorrect because hospice care does not aim to prolong life, but rather to provide comfort and quality of life for the client and the family.

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A nurse is caring for a client who is in labour and notes that the umbilical cord is prolapsed. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["13"]

Explanation

A hospice nurse is consulting with a client and her family about receiving home services. Which of the following statements should the nurse identify as an indication that the family understands home hospice care?

Correct Answer is A

Explanation

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