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. Uterine atony.
Uterine atony is the failure of the uterus to contract and retract after delivery, which can lead to excessive bleeding and hemorrhage.A boggy uterus on palpation is a sign of uterine atony.
Choice B. Uterine inversion is wrong because it is a rare complication in which the uterus turns inside out and protrudes through the cervix.It usually causes severe pain, shock, and hemorrhage.
Choice C. Uterine rupture is wrong because it is a life-threatening emergency in which the uterus tears open along the scar line of a previous cesarean delivery or other uterine surgery.It usually causes severe abdominal pain, fetal distress, and maternal hypovolemic shock.
Choice D. Uterine infection is wrong because it is an inflammation of the endometrium (the lining of the uterus) caused by bacteria.It usually causes fever, foul-smelling lochia, and lower abdominal tenderness.
Normal ranges for postpartum bleeding are about 500 ml for vaginal delivery and 1000 ml for cesarean delivery.The uterus should feel firm and midline at or below the umbilicus after delivery.
Correct Answer is A
Explanation
The correct answer is choice A. Normal involution.
This means that the uterus is returning to its pre-pregnancy size and position after delivery.
The fundus is the upper part of the uterus and it should be firm, midline, and gradually descend into the pelvis.A fundus that is 2 cm below the umbilicus at 4 hours postpartum is within the normal range.
Choice B. Subinvolution is wrong because it refers to a delayed or incomplete involution of the uterus.
This can result in prolonged bleeding, infection, or retained placental fragments.A fundus that is above the umbilicus, boggy, or displaced to one side may indicate subinvolution.
Choice C. Retained placenta is wrong because it means that some or all of the placenta remains in the uterus after delivery.
This can cause heavy bleeding, infection, or uterine atony.A fundus that is high, soft, or tender may indicate retained placenta.
Choice D. Endometritis is wrong because it means that the lining of the uterus is inflamed due to infection.
This can cause fever, foul-smelling lochia, pelvic pain, or uterine tenderness.A fundus that is enlarged, tender, or malodorous may indicate endometritis.
Normal ranges for fundal height after delivery are:
• Immediately after delivery:
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