The nurse performs a vaginal assessment on a pregnant client in labor. On assessment, the nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following is the initial nursing action?
1. Place the client in Trendelenburg's position.
2. Gently push the cord into the vagina.
3. Find the closest telephone, and page the physician stat.
4. Call the delivery room to notify the staff that the client will be transported imme-diately.
1
Rationale: When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with her hips higher than her head to shift the fetal presenting part toward the diaphragm. The nurse should push the call light to summon help, and other staff members should call the physician and notify the delivery room. If the cord is protruding from the vagina, no attempt should be made to replace it because that could traumatize it and further reduce blood flow. Oxygen at 8 to 10 L/min by face mask is ad-ministered to the mother to increase fetal oxygenation.
You might also like to view...
A client is prescribed a nonsteroidal anti-inflammatory drug (NSAID) for treatment of gout. Which nursing instruction should be provided?
1. "Your initial dose will be low during your acute attack, but we will raise it over the next few weeks." 2. "This drug will help with inflammation, but I will give you a second medication for pain." 3. "If you have stomach pain, please call me for a medication adjustment." 4. "You may find that you cannot sleep while taking this medication."
Which assessment data is a precipitating factor for insomnia?
A) Frequent worrying B) Loss of a job C) Inadequate coping skills D) Hyperarousal
The nurse using the Hirschberg test would expect to find which of the following in a child with normal eyes?
a. the light reflected symmetrically in the center of both corneas b. the light reflecting red on the optic nerve c. arteries and veins in the proper proportion d. no evidence of retinal detachment
The nurse plans to teach a class about Alzheimer's disease to a caregiver's support group. What will the best plan by the nurse include? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply
1. Depression and aggressive behavior are common with the disease. 2. Alzheimer's disease accounts for about 50% of all dementias. 3. Glutamergic inhibitors are the most common class of drugs for treating Alzheimer's disease. 4. Chronic inflammation of the brain may be a cause of the disease. 5. Memory difficulties are an early symptom of the disease.