Author Question: As the nurse prepares a client for a vaginal examination, a loop of pulsating umbilical cord is ... (Read 29 times)

brutforce · **on:** Jun 27, 2018

As the nurse prepares a client for a vaginal examination, a loop of pulsating umbilical cord is observed at the vaginal introitus. What is the priority nursing action?

a. Listen for the fetal heart tones with a Doppler device or electronic fetal monitor.
b. Perform a vaginal exam, and elevate the presenting part of the cord.
c. Prepare her for immediate cesarean delivery.
d. Put on a sterile glove and gently reinsert the cord into the vaginal opening.

Question 2

A woman gave birth 48 hours ago to a healthy infant girl. She has decided to bottle-feed. During your assessment you notice that both of her breasts are swollen, warm, and tender on palpation.

The woman should be advised that this condition can best be treated by: a. Running warm water on her breasts during a shower.
b. Applying ice to the breasts for comfort.
c. Expressing small amounts of milk from the breasts to relieve pressure.
d. Wearing a loose-fitting bra to prevent nipple irritation.

cloudre37 · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

B
The priority with a prolapsed cord is to decrease the pressure on the cord as soon as possible. Listening for the fetal heart tones with a Doppler device or electronic fetal monitor and preparing her for immediate cesarean delivery are important interventions, but they are not the highest priority. Putting on a sterile glove and gently reinserting the cord into the vaginal opening may increase the pressure on the cord and further compromise the fetus.

Answer to Question 2

B

Feedback
A This woman is experiencing engorgement, which can be treated by using ice packs (because she is not breastfeeding) and cabbage leaves.
B This intervention is appropriate for treating engorgement in a mother who is bottle-feeding.
C A bottle-feeding mother should avoid any breast stimulation, including pumping or expressing milk.
D A bottle-feeding mother should wear a well-fitted support bra or breast binder continuously for at least the first 72 hours after giving birth. A loose-fitting bra will not aid lactation suppression. Furthermore, the shifting of the bra against the breasts may stimulate the nipples and thereby stimulate lactation.