Which of these clients is at greatest risk for umbilical cord prolapse?
A client who is pregnant with twins
A client who has gestational hypertension
A client who has oligohydramnios
A client who has placenta previa.
The Correct Answer is C
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.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
The correct answer is choice D. A loop of umbilical cord protruding from her vagina.This is a sign of umbilical cord prolapse, which is a medical emergency that occurs when the cord slips past the fetal presenting part and becomes compressed, reducing blood flow and oxygen to the fetus.The nurse should immediately call for help, place the woman in a knee-chest or Trendelenburg position, insert two fingers into the vagina and lift the presenting part off the cord, cover the cord with sterile saline-soaked gauze, administer oxygen, and prepare for an emergency cesarean delivery.
Choice A is wrong because a sudden increase in fetal heart rate variability is not a specific sign of cord prolapse.It may indicate fetal well-being or distress depending on the pattern and duration of the variability.
Choice B is wrong because a large amount of clear amniotic fluid is not a sign of cord prolapse.It may indicate rupture of membranes, which is a risk factor for cord prolapse if the presenting part is not engaged.
Choice C is wrong because a change in fetal heart rate from 140 to 90 bpm is not a sign of cord prolapse.It may indicate fetal bradycardia, which can have many causes such as hypoxia, acidosis, medication effects, or fetal sleep cycle.
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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