During the nursing assessment of a woman with ruptured membranes, the nurse suspects a prolapsed umbilical cord. The nurse's priority action is to:
1. Help the fetal head descend faster.
2. Use gravity and manipulation to relieve compression on the cord.
3. Facilitate dilation of the cervix with prostaglandin gel.
4. Prevent head compression.
2
Rationale:
1. The fetal head's descending would put further pressure on the umbilical, and reduce blood flow and oxygenation to the fetus.
2. The number one priority is to relieve compression on the umbilical cord to allow blood flow to reach the fetus. A C-section is imminent.
3. Further dilatation of the cervix, or descent of the head, is unnecessary in light of the impending C-section.
4.Head compression is not a concern in the case of prolapsed of the umbilical cord. The cord is what will be compressed.
You might also like to view...
Which of the following best describes where the majority of time is spent by a community health nurse?
a. Caring for individuals b. Caring for families c. Caring for groups d. Caring for aggregates
A 19-year-old client was admitted to the emergency department after a bicycle accident complaining of low back pain. Hematuria was present. For accurate monitoring of output, the nurse should:
A) insert a Foley catheter. B) measure all voided urine. C) weigh the sheets and reweigh periodically. D) keep the client on the bedpan.
A pregnant woman comes into the ED after receiving minor blunt trauma to her abdomen during a minor car accident. The nurse should carefully evaluate the woman for:
1. disseminated intravascular coagulation. 2. the ABCs of resuscitation. 3. abruptio placentae. 4. cervical funneling.
Which medications could cause gastric bleeding? Briefly explain how