The nurse recognizes that which fetal presentation increases a patient’s risk for umbilical cord prolapse? (Select all that apply).
Vertex
Breech
Transverse lie
Face
Brow
Correct Answer : B,C,D,E
The correct answer is choice B, C, D and E. These are all fetal presentations that increase a patient’s risk for umbilical cord prolapse. Umbilical cord prolapse is when the umbilical cord comes out of the uterus with or before the presenting part of the baby. This can cause fetal hypoxia and brain damage due to cord compression.
Choice A is wrong because vertex presentation is the most common and normal fetal position, where the head is down and fully flexed.
This does not increase the risk of cord prolapse.
Normal ranges for fetal presentation are:
• Vertex: 95% of term deliveries.
• Breech: 3% to 4% of term deliveries.
• Transverse lie: 0.5% of term deliveries.
• Face: 0.2% of term deliveries.
• Brow: 0.1% of term deliveries.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. A client who has oligohydramnios.
Oligohydramnios is a condition where there is too little amniotic fluid around the fetus.This can cause the umbilical cord to slip down into the cervix or vagina before the baby, resulting in cord prolapse.
Cord prolapse can cut off the blood and oxygen supply to the baby and cause fetal distress or death.
Choice A is wrong because a client who is pregnant with twins is not at greater risk for cord prolapse unless there is also malpresentation of the fetuses, such as breech or transverse lie.
Choice B is wrong because a client who has gestational hypertension is not at greater risk for cord prolapse unless there is also polyhydramnios, which is excessive amniotic fluid around the fetus.
Choice D is wrong because a client who has placenta previa is not at greater risk for cord prolapse unless there is also artificial rupture of membranes by doctors.
Correct Answer is A
Explanation
The correct answer is choiceA.
The nurse should instruct the client to avoid lifting anything heavier than the newborn for 6 weeks.This is because lifting heavy objects can strain the abdominal muscles and the incision site, and increase the risk of bleeding and infection.
ChoiceBis wrong because the nurse should advise the client to wait at least 4 to 6 weeks before resuming sexual intercourse.This is to allow the incision to heal and prevent infection and discomfort.
ChoiceCis wrong because the nurse should not recommend ibuprofen for pain relief as it can interfere with blood clotting and increase bleeding.The nurse should suggest acetaminophen or a prescribed analgesic instead.
ChoiceDis wrong because the nurse should not tell the client to report any foul-smelling vaginal discharge to the provider.
The client should expect some vaginal discharge (lochia) for several weeks after a cesarean delivery, which may have a mild odor.However, the nurse should instruct the client to report signs of infection such as fever, chills, redness, swelling, or increased pain at the incision site.
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