The practical nurse (PN) is assigned to assist in the care of a laboring client at 42-weeks gestation. While providing perineal care, the PN observes the umbilical cord protruding from the vagina. Which action should the PN take?

Support the client's upper body and knees with pillows.

Encourage the client to push with the next contraction.

Assist the team to prepare for a possible cesarean delivery.

Gently wrap the cord with a dry sterile dressing.

Answer and Explanation

The Correct Answer is C

The umbilical cord prolapse is an emergency situation that requires immediate intervention. The PN should not attempt to push the cord back into the vagina or cover it with a dry sterile dressing. Instead, the PN should notify the healthcare provider and the obstetrical team and assist in preparing for an emergency cesarean delivery.

Option A and B may be appropriate in some situations, but they are not the priority in this scenario.

Therefore, options A, B, and D are not answers because they do not address the immediate emergency of umbilical cord prolapse.

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Correct Answer is B

Explanation

If the client in active labor expresses a desire to empty her bladder and her vaginal exam is unchanged, the practical nurse (PN) should assist her up to the bathroom. An empty bladder can help facilitate labor progress.

Reviewing the fetal heart rate pattern (A) is important, but it is not the most appropriate action in response to the client's request to empty her bladder. Checking the perineum for changes in "show" or discharge (C) is also important, but it is not the most appropriate action in this situation. Obtaining a straight catheter kit to empty the client's bladder (D) may be necessary if she is unable to empty her bladder on her own, but assisting her up to the bathroom should be attempted first.

A. Mindfulness. B. Guided imagery. C. Biofeedback. D. Cognitive reframing.

Correct Answer is B

Explanation

Guided imagery is a technique that can help the client to relax and reduce anxiety by imagining a peaceful and calming scene. This technique can be helpful for clients waiting for surgery to reduce stress and promote relaxation.

Option A (mindfulness) may also be helpful, but it may require more practice and preparation than guided imagery.

Option C (biofeedback) may not be feasible in the preoperative holding area, and

Option D (cognitive reframing) may not be helpful in the immediate preoperative period.

Therefore, options A, C, and D are not answers because they may not be the most eﬀective technique to help the client in the preoperative holding area.

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The practical nurse (PN) is assigned to assist in the care of a laboring client at 42-weeks gestation. While providing perineal care, the PN observes the umbilical cord protruding from the vagina. Which action should the PN take?

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Correct Answer is B

Explanation

The practical nurse (PN) is caring for a client in the preoperative holding area who is waiting for abdominal surgery. The client tells the PN about feeling afraid and anxious because of the surgery. Which technique is best for the PN to assist the client to use while waiting for surgery?

Correct Answer is B

Explanation

The practical nurse (PN) is assigned to assist in the care of a laboring client at 42-weeks gestation. While providing perineal care, the PN observes the umbilical cord protruding from the vagina. Which action should the PN take?

An older female client is admited to the orthopedic unit following surgical repair of a fractured hip. On the second postoperative day, the client becomes confused and repeatedly asks the practical nurse (PN) where she is. Which information should the PN obtain before reporting to the charge nurse?

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The practical nurse (PN) is interviewing a middle-aged married male who is being treated for depression and reports an increasing lack of interest in sexual intimacy with his wife. Which information is most important for the PN to obtain?

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The practical nurse (PN) is caring for a client that has just arrived in the emergency department with 2nd degree thermal burns to the right thigh, lower leg and foot, and reports severe pain in the right leg. Which priority action should the PN take while caring for this patient?

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