(Solved) Carla Hernandez Pre/Post-test
A woman in active labor reports to the nurse that she thinks that her bag of waters has
broken. What is the first assessment that the nurse performs at this time?
- Monitor the fetal heart rate and pattern
Explanation: When the fetal membranes rupture, then the presenting part can put
pressure on the umbilical cord. the first assessment to make is the fetal heart rate and
pattern to ensure the fetus is getting enough oxygen through the umbilical cord
The labor and delivery nurse notices that a laboring woman's external fetal monitor
shows a variable deceleration. what is the common etiology of this non-reassuring fetal
periodic pattern?
- Cord compression
Explanation: Fetal variable decelerations are commonly associated with umbilical cord
compression
Which of the following statements is true concerning prolapsed umbilical cord?
- It is an emergency that requires immediate measures to minimize the fetal mortality or
morbidity from hypoxia
Explanation: The occurrence of the prolapsed umbilical cord is approximately 1 in 300
-600 births, or 3% of the cephalic presentations and 3.7% of breech presentations.
A prolapsed umbilical cord is an obstetric emergency that requires immediate attention
to prevent acidosis from the fetal hypoxia.
The nurse is admistting a labor woman at 39 weeks gestation. Which of the following
are risk factors for prolapsed umbilical cord (sata)
- Estimated fetal weight of 2,400 g (5 lb, 1 oz)
Amniotomy performed at station -2
Multiple gestation
Amniotic fluid 2,200 mL
Explanation: risk factors for an umbilical cord prolapse incude the following" Low birth
weight, being second twins, transverse lie, breech presentation, preterm labor (less than
37 weeks), Poly hydramnios (greater than 2,000 mL), amniotomy (especially when fetus
is not engaged), prematuer rupture of the membranes, placenta previa, and a long cord
Which of the following nursing measures has the highest priority when an intrapartum
woman has a prolapsed umbilical cord?
- Place sterile gloved hand into patient's vagina to push the fetus off the umbilical cord
, Explanation: The immediate concern is to reestablish blood flow through the umbilical
cord. Why, the nurse would push the presenting part off the cord to relieve the
compression.
Position changes to relieve compression:
knee-to-chest, trendelenburg, hips higher than chest, modified Sims
The nurse takes measures to preserve the integrity of the visible umbilical cord prolapse
to maintain blood flow to the fetus. Which of the following are appropriate measures?
- Assess the exposed umbilical cord for color and pulsation
Use a gloved hand to lift the presenting part of the cord
Explanation: The nurse would try to reestablish blood flow to the fetus by placing a
gloved hand into the vagina and lifting the presenting part off of the cord
The exposed umbilical cord is not pushed back into the vagina, because this action
could cause the umbilical vessels to be kinked and cut off the blood flow to the fetus
What is the primary purpose for a provider order for terbutaline sulfate to be given to a
laboring patient who presents with a prolapsed umbilical cord?
- To relax the uterine smooth muscles to allow for improved fetal blood flow
Explanation: This medication is being used as a tocolytic agent, which inhibits uterine
contractions.
The primary reason for its administration is to prevent smooth muscle contractions of
the uterus to allow for an immediate C-section
A laboring woman called the nurse to report her bag of water broke and she feels a
pulsation in her vagina. The nurse notes variable decelerations with fetal bradycardia on
the fetal monitor and suspects prolapsed umbilical cord.
Put into order he interventions the nurse should perform:
- 1) Call the charge nurse to notify the provider and prepare for immediate delivery
2) Insert a gloved hand into the vagina to relieve pressure on the umbilical cord
3) Assist the patient into the knee-chest position
4) Administer oxygen by non-rebreather mask at 10 L/min
5) Explain emergency measures and rationales to the patient and her support person
6) Ensure that there are no further abnormal fetal heart rate patterns
A woman in active labor reports to the nurse that she thinks that her bag of waters has
broken. What is the first assessment that the nurse performs at this time?
- Monitor the fetal heart rate and pattern
Explanation: When the fetal membranes rupture, then the presenting part can put
pressure on the umbilical cord. the first assessment to make is the fetal heart rate and
pattern to ensure the fetus is getting enough oxygen through the umbilical cord
The labor and delivery nurse notices that a laboring woman's external fetal monitor
shows a variable deceleration. what is the common etiology of this non-reassuring fetal
periodic pattern?
- Cord compression
Explanation: Fetal variable decelerations are commonly associated with umbilical cord
compression
Which of the following statements is true concerning prolapsed umbilical cord?
- It is an emergency that requires immediate measures to minimize the fetal mortality or
morbidity from hypoxia
Explanation: The occurrence of the prolapsed umbilical cord is approximately 1 in 300
-600 births, or 3% of the cephalic presentations and 3.7% of breech presentations.
A prolapsed umbilical cord is an obstetric emergency that requires immediate attention
to prevent acidosis from the fetal hypoxia.
The nurse is admistting a labor woman at 39 weeks gestation. Which of the following
are risk factors for prolapsed umbilical cord (sata)
- Estimated fetal weight of 2,400 g (5 lb, 1 oz)
Amniotomy performed at station -2
Multiple gestation
Amniotic fluid 2,200 mL
Explanation: risk factors for an umbilical cord prolapse incude the following" Low birth
weight, being second twins, transverse lie, breech presentation, preterm labor (less than
37 weeks), Poly hydramnios (greater than 2,000 mL), amniotomy (especially when fetus
is not engaged), prematuer rupture of the membranes, placenta previa, and a long cord
Which of the following nursing measures has the highest priority when an intrapartum
woman has a prolapsed umbilical cord?
- Place sterile gloved hand into patient's vagina to push the fetus off the umbilical cord
, Explanation: The immediate concern is to reestablish blood flow through the umbilical
cord. Why, the nurse would push the presenting part off the cord to relieve the
compression.
Position changes to relieve compression:
knee-to-chest, trendelenburg, hips higher than chest, modified Sims
The nurse takes measures to preserve the integrity of the visible umbilical cord prolapse
to maintain blood flow to the fetus. Which of the following are appropriate measures?
- Assess the exposed umbilical cord for color and pulsation
Use a gloved hand to lift the presenting part of the cord
Explanation: The nurse would try to reestablish blood flow to the fetus by placing a
gloved hand into the vagina and lifting the presenting part off of the cord
The exposed umbilical cord is not pushed back into the vagina, because this action
could cause the umbilical vessels to be kinked and cut off the blood flow to the fetus
What is the primary purpose for a provider order for terbutaline sulfate to be given to a
laboring patient who presents with a prolapsed umbilical cord?
- To relax the uterine smooth muscles to allow for improved fetal blood flow
Explanation: This medication is being used as a tocolytic agent, which inhibits uterine
contractions.
The primary reason for its administration is to prevent smooth muscle contractions of
the uterus to allow for an immediate C-section
A laboring woman called the nurse to report her bag of water broke and she feels a
pulsation in her vagina. The nurse notes variable decelerations with fetal bradycardia on
the fetal monitor and suspects prolapsed umbilical cord.
Put into order he interventions the nurse should perform:
- 1) Call the charge nurse to notify the provider and prepare for immediate delivery
2) Insert a gloved hand into the vagina to relieve pressure on the umbilical cord
3) Assist the patient into the knee-chest position
4) Administer oxygen by non-rebreather mask at 10 L/min
5) Explain emergency measures and rationales to the patient and her support person
6) Ensure that there are no further abnormal fetal heart rate patterns
