The nurse notices a decreased fetal heart rate (FHR) on the fetal monitor tracing and contacts the charge nurse. The charge nurse completes a vaginal exam and can feel a portion of the umbilical cord in the vagina.
Which emergency interventions will the charge nurse implement? Select all that apply.
Prepare the client for emergency cesarean delivery
Position the client in a knee-chest position and call for help
Locate and insert a vacuum suction catheter into the vagina and push the infant back into the uterus
Keep a gloved hand in the vagina and push upward on the presenting part to keep it off the cord
Contact the provider and report a prolapsed umbilical cord
Correct Answer : A,B,D,E
A. Preparing the client for emergency cesarean delivery is often necessary when a prolapsed umbilical cord is identified.
B. Positioning the client in a knee-chest position helps alleviate pressure on the umbilical cord, improving fetal oxygenation.
C. Inserting a vacuum suction catheter into the vagina and pushing the infant back into the uterus is not a recommended intervention for a prolapsed umbilical cord; this action may cause harm to the fetus.
D. Keeping a gloved hand in the vagina and pushing upward on the presenting part helps relieve pressure on the umbilical cord.
E. Contacting the provider and reporting a prolapsed umbilical cord is essential for prompt communication and decision-making.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While shape and height are important aspects, tone is also a key component in assessing the fundus after childbirth.
B. Position is part of the assessment, but the shape and tone are equally crucial components.
C. This choice correctly includes all the essential aspects of a fundal assessment: tone, shape, and position.
D. While shape and height are important, tone and position are equally vital components in assessing the fundus.
Correct Answer is ["100"]
Explanation
To calculate the flow rate in mL/hr, we need to use the following formula:
Flow rate (mL/hr) = Dose (mU/min) x Volume (mL) / Concentration (units)
In this case, the dose is 2 mU/min, the volume is 1000 mL, and the concentration is 20 units. Plugging these values into the formula, we get:
Flow rate (mL/hr) = 2 x 1000 / 20 Flow rate (mL/hr) = 2000 / 20 Flow rate (mL/hr) = 100
Therefore, the flow rate in mL/hr is 100.
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