Which statement by a pregnant client indicates understanding of measures to prevent umbilical cord prolapse?
“I will avoid squatting or sitting on hard surfaces.”
“I will report any decrease in fetal movement to my provider.”
“I will come to the hospital as soon as my water breaks.”
“I will drink plenty of fluids and rest on my left side.”.
The Correct Answer is C
The correct answer is choice C. “I will come to the hospital as soon as my water breaks.” This statement indicates understanding of measures to prevent umbilical cord prolapse, which is a complication that occurs when the umbilical cord drops out of the cervix before the baby during labor. This can cut off the baby’s blood and oxygen supply and cause permanent brain damage. Immediate delivery by C-section is usually necessary.
Choice A is wrong because squatting or sitting on hard surfaces does not increase the risk of umbilical cord prolapse.
Choice B is wrong because decreased fetal movement is not a sign of umbilical cord prolapse, but rather a sign of fetal distress that may have other causes.
Choice D is wrong because drinking plenty of fluids and resting on the left side are general measures to promote maternal and fetal well-being, but they do not prevent umbilical cord prolapse.
Some of the risk factors for umbilical cord prolapse include premature rupture of membranes, multiple pregnancy, breech presentation, excessive amniotic fluid, abnormal length of the umbilical cord and premature delivery. Some of the symptoms of umbilical cord prolapse include visible or palpable cord after water breaks, fetal heart rate abnormalities and maternal feeling of something coming out of the vagina. Umbilical cord prolapse can be diagnosed by physical examination, ultrasound or fetal heart rate monitoring.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. “I will avoid squatting or sitting on the toilet after my water breaks.” This statement indicates that the patient understands how to prevent umbilical cord prolapse, which is a rare but serious complication that occurs when the umbilical cord slips out of the cervix before the baby during labor.This can cut off the baby’s blood and oxygen supply and require immediate delivery.
Choice B is wrong because drinking plenty of fluids does not affect the amniotic fluid level, which is determined by the placenta and the baby’s kidneys.Excessive amniotic fluid (polyhydramnios) can actually increase the risk of umbilical cord prolapse.
Choice C is wrong because monitoring the baby’s movements does not prevent umbilical cord prolapse, although it can help detect fetal distress if the cord is compressed.Decreased fetal movements can have other causes besides cord prolapse, such as fetal sleep cycle, maternal medication, or placental insufficiency.
Choice D is wrong because sleeping on the left side does not prevent umbilical cord prolapse, although it can improve blood flow to the baby and reduce the risk of supine hypotension syndrome.Umbilical cord prolapse can occur regardless of the maternal position.
Normal ranges for amniotic fluid index (AFI) are 5 to 25 cm.Normal ranges for fetal heart rate (FHR) are 110 to 160 beats per minute (bpm).
Correct Answer is C
Explanation
The correct answer is choice C. Apply pressure to presenting part with hand.
This is because cord prolapse is an emergency situation that requires immediate delivery to save the fetus.Applying pressure to the presenting part with hand can help relieve the compression of the cord and maintain fetal oxygenation until delivery.
Choice A is wrong because stopping oxytocin infusion will not prevent cord compression or fetal hypoxia.Oxytocin may be stopped after applying pressure to the presenting part and notifying the physician.
Choice B is wrong because placing the patient in knee-chest position may not be effective in relieving cord compression.
It may also be uncomfortable and difficult for the patient to maintain.A better position would be Trendelenburg or modified Sims.
Choice D is wrong because administering oxygen via non-rebreather mask is not a priority action.Oxygen may be given after applying pressure to the presenting part and notifying the physician, but it will not improve fetal oxygenation if the cord is compressed.
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