A nurse is preparing a client for an emergency cesarean birth due to umbilical cord prolapse.
Which of the following interventions should the nurse include in the preoperative care? (Select all that apply.).
Insert an indwelling urinary catheter
Administer an IV fluid bolus as prescribed
Obtain informed consent from the client or her partner
Perform a leopold maneuver to determine fetal position.
Apply an external fetal monitor to assess fetal heart rate
Correct Answer : A,B,C
The correct answer is choice A, B and C. These interventions are part of the preoperative care for a client who is undergoing an emergency cesarean birth due to umbilical cord prolapse. Umbilical cord prolapse is a medical emergency that occurs when the umbilical cord slips through the cervix and into the vagina before the baby, causing fetal hypoxia.
Choice D is wrong because performing a leopold maneuver to determine fetal position is not necessary in this situation, as the fetal presentation is already known and the priority is to deliver the baby as soon as possible.
Choice E is wrong because applying an external fetal monitor to assess fetal heart rate is not sufficient in this situation, as the cord compression may cause severe bradycardia or variable decelerations. The nurse should manually lift the presenting part and hold it off the prolapsed cord while preparing for cesarean delivery.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
The correct answer is choice A, B and C. These interventions are part of the preoperative care for a client who is undergoing an emergency cesarean birth due to umbilical cord prolapse.Umbilical cord prolapse is a medical emergency that occurs when the umbilical cord slips through the cervix and into the vagina before the baby, causing fetal hypoxia.
Choice D is wrong because performing a leopold maneuver to determine fetal position is not necessary in this situation, as the fetal presentation is already known and the priority is to deliver the baby as soon as possible.
Choice E is wrong because applying an external fetal monitor to assess fetal heart rate is not sufficient in this situation, as the cord compression may cause severe bradycardia or variable decelerations.The nurse should manually lift the presenting part and hold it off the prolapsed cord while preparing for cesarean delivery.
Correct Answer is A
Explanation
A nitrazine test is a conventional test that uses pH testing of leaked amniotic fluid.Amniotic fluid is alkaline and turns the nitrazine paper blue, while vaginal secretions are acidic and turn the paper yellow or green.
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