Author Question: During a vaginal exam, the nurse palpates a loop of prolapsed umbilical cord beside the fetal head. ... (Read 93 times)

jenna1 · **on:** Jun 27, 2018

During a vaginal exam, the nurse palpates a loop of prolapsed umbilical cord beside the fetal head. The nurse has the client's husband assist the client onto her hands and knees while the nurse supports the fetal head.

The rationale for this action is to a. help the fetal head descend faster
b. prevent head compression during contractions
c. facilitate rapid dilation of the cervix
d. relieve compression of the cord through gravity and manipulation

Question 2

A 4-year-old has acute glomerulonephritis, and is admitted to the hospital. Which is an appropriate nursing diagnosis for this child?

1. Risk for injury related to loss of blood in urine
2. Fluid volume excess related to decreased plasma filtration
3. Risk for infection related to hypertension
4. Altered growth and development related to a chronic disease

lorealeza77 · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

D
The purpose of having the client's husband assist the client onto her hands and knees while the nurse supports the fetal head is to relieve compression of the cord through gravity and manipulation. The nurse would not want the fetal head to descend faster, because it would put more pressure on the prolapsed cord. Preventing head compression during contractions is a result of the intervention; it is not the primary goal, as the scenario doesn't tell you about the presenting part. Facilitating rapid dilation of the cervix is not the purpose of the intervention.

Answer to Question 2

2
Rationale:
1. In acute glomerulonephritis, there is no risk for injury, because the blood loss in the urine is not such that it causes anemia.
2. In acute glomerulonephritis, the fluid is excessive, and fluid and electrolyte balance should be monitored.
3. In acute glomerulonephritis, while a risk for infection might be present, it is not related to the hypertension.
4. Growth and development are not normally affected in acute glomerulonephritis, because this is an acute process, not a chronic one.