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1.The nurse is assessing for stoma prolapse in a client with a colostomy. The nurse would observe which of the following if stoma prolapse occurred?
- Sunken and hidden stoma
- Dark- and bluish-colored stoma
- Narrowed and flattened stoma
- Protruding stoma
2.During the period of induction of labor, a client should be observed carefully for signs of:
- Severe pain
- Uterine tetany
- Umbilical cord prolapse
3.A nurse is monitoring a client in labor who is receiving Pitocin and notes that the client is experiencing hypertonic uterine contractions. List in order of priority the actions that the nurse takes.
- Stop of Pitocin infusion
- Perform a vaginal examination
- Reposition the client
- Check the client’s blood pressure and heart rate
- Administer oxygen by face mask at 8 to 10 L/min
4.A nurse in the labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following would be the initial nursing action?
- Place the client in Trendelenburg’s position
- Call the delivery room to notify the staff that the client will be transported immediately
- Gently push the cord into the vagina
- Find the closest telephone and stat page the physician
5.Which of the following complications during a breech birth the nurse needs to be alarmed?
- Abruption placenta.
- Caput succedaneum.
- Pathological hyperbilirubinemia.
- Umbilical cord prolapse.
6.The nurse is taking care of a multipara who is at 42 weeks of gestation and in active labor, her membranes ruptured spontaneously 2 hours ago. While auscultating for the point of maximum intensity of fetal heart tones before applying an external fetal monitor, the nurse counts 100 beats per minute. The immediate nursing action is to:
- Start oxygen by mask to reduce fetal distress.
- Examine the woman for signs of a prolapsed cord.
- Turn the woman on her left side to increase placental perfusion.
- Take the woman’s radial pulse while still auscultating the FHR.
7.When the bag of waters ruptures spontaneously, the nurse should inspect the vaginal introitus for possible cord prolapse. If there is part of the cord that has prolapsed into the vaginal opening the correct nursing intervention is:
- Push back the prolapse cord into the vaginal canal
- Place the mother on semifowler’s position to improve circulation
- Cover the prolapse cord with sterile gauze wet with sterile NSS and place the woman on trendellenberg position
- Push back the cord into the vagina and place the woman on sims position
8.A patient is in labor and has just been told she has a breech presentation. The nurse should be particularly alert for which of the following?
- Ophthalmia neonatorum
- Prolapsed umbilical cord
9.Which of the following is the nurse’s initial action when umbilical cord prolapse occurs?
- Begin monitoring maternal vital signs and FHR
- Place the client in a knee-chest position in bed
- Notify the physician and prepare the client for delivery
- Apply a sterile warm saline dressing to the exposed cord
10. When assessing a laboring client, the nurse finds a prolapsed cord. The nurse should:
- Attempt to replace the cord
- Place the client on her left side
- Elevate the client’s hips
- Cover the cord with a dry, sterile gauze
Answers and Rationale
- D. A prolapsed stoma is one which the bowel protruded through the stoma. A stoma retraction is characterized by sinking of the stoma. Ischemia of the stoma would be associated with dusky or bluish color. A stoma with a narrowed opening at the level of the skin or fascia is said to be stenosed.
- Answer: B. Uterine tetany. Uterine tetany could result from the use of oxytocin to induce labor. Because oxytocin promotes powerful uterine contractions, uterine tetany may occur. The oxytocin infusion must be stopped to prevent uterine rupture and fetal compromise.
- Answer: A, D, B. E, C. If uterine hypertonicity occurs, the nurse immediately would intervene to reduce uterine activity and increase fetal oxygenation. The nurse would stop the Pitocin infusion and increase the rate of the nonadditive solution, check maternal BP for hyper or hypotension, position the woman in a side-lying position, and administer oxygen by snug face mask at 8-10 L/min. The nurse then would attempt to determine the cause of the uterine hypertonicity and perform a vaginal exam to check for prolapsed cord.
- Answer: A. Place the client in Trendelenburg’s position. When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with the hips higher than the 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. No attempt should be made to replace the cord. The examiner, however, may place a gloved hand into the vagina and hold the presenting part off of the umbilical cord. Oxygen at 8 to 10 L/min by face mask is delivered to the mother to increase fetal oxygenation.
- D. Because umbilical cord’s insertion site is born before the fetal head, the cord may be compressed by the after-coming head in a breech birth.
- D. Taking the mother’s pulse while listening to the FHR will differentiate between the maternal and fetal heart rates and rule out fetal Bradycardia.
- Answer: (C) Cover the prolapse cord with sterile gauze wet with sterile NSS and place the woman on trendellenberg position. The correct action of the nurse is to cover the cord with sterile gauze wet with sterile NSS. Observe strict asepsis in the care of the cord to prevent infection. The cord has to be kept moist to prevent it from drying. Don’t attempt to put back the cord into the vagina but relieve pressure on the cord by positioning the mother either on trendellenberg or sims position
- D. In a breech position, because of the space between the presenting part and the cervix, prolapse of the umbilical cord is common. Quickening is the woman’s first perception of fetal movement. Ophthalmia neonatorum usually results from maternal gonorrhea and is conjunctivitis. Pica refers to the oral intake of nonfood substances.
- B. The immediate priority is to minimize pressure on the cord. Thus the nurse’s initial action involves placing the client on bed rest and then placing the client in a knee-chest position or lowering the head of the bed, and elevating the maternal hips on a pillow to minimize the pressure on the cord. Monitoring maternal vital signs and FHR, notifying the physician and preparing the client for delivery, and wrapping the cord with sterile saline soaked warm gauze are important. But these actions have no effect on minimizing the pressure on the cord.
- Answer C is correct. The client with a prolapsed cord should be treated by elevating the hips and covering the cord with a moist, sterile saline gauze. The nurse should use her fingers to push up on the presenting part until a cesarean section can be performed. Answers A, B, and D are incorrect. The nurse should not attempt to replace the cord, turn the client on the side, or cover with a dry gauze.