NUR 306: Vsim Carla Hernandez Pre/Post-test
A laboring woman called the nurse to report her bag of water broke and she feels a pulsatio in her vagina. The nurse notes cariable deelerations with fetal bradycardia on the fetal monitor and sispects 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 umbilica cord 3) assist the patient into the knee-chest position 4) administed oxygen by nonrebreather mask at 10 L/min 5) Explain emergency measuers and rationales to the patient and her support person 6) Ensure that there are further abnormal fetal heart rate patterns 7) Document the actions and procedures taken to resolve this situation
The nurse received report for Carla Hernandez before taking over her care. What was the most important piece of information communicated to the nurse that expedited care of this patient?
Amniotomy performed by provider to facilitate labor. explanation: peformed amniotomy is a risk factor for prolapsed umbilical cord prolapse.
What is the most important action the nurse would take when a prolapsed cord has been identified?
Apply gloved hand in the vagina to alleviate cord compression.
Which of the following statements is true concerning prolapsed umbilical cord?
It is an emergency that requireds immediate measures to minimize the fetal mortality or mobidity from hypoxia Explanation: The occurence 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 umbilibal cord is an obstetric emergency that requires immediate attention to prevent acidosis from the fetal hypoxia.
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? (sata)
Assess the exposed umbilical cord for color and pulsation Use a gloced 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 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
Carla Hernandez's fetal membranes were ruptured by her provider. Immediately following the procedure, the nurse notes persistent fetal bradycardia on the fetal monitor. This could indicate which of the following?
Compression of 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 ompression
As Carla Hernandez is taken back to the operating room for an emergent cesarean delivery, her husband expresses anxiety about his wife and his baby. What is the most therapeutic communication that the nurse can make?
Delivery is needed because the blood flow through the umbilical cord is not getting enough oxygen to the baby. I understand that you are concerned about the well-being of your wife and baby. What are you feeling?
he 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 diagnoses has the highest priority in the care of Carla Hernandez during an umbilical cord prolapse?
Impaired gas exchange in the fetus related to decreased blood perfusion.
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
After the umbilical cord prolapse has been identified, which of the following personnel should the nurse inform of this emergency? (select all that apply)
NICU Surgery Provider
To prepare for an immediate cesarean delivery for Carla Hernandez, what would the nurse do first?
Obtain an informed consent
The nurse is preparing for an emergency cesarean birth for a patient who has prolapsed cord visible at the vulva. Which interventions would the nurse take for this surgical procedure? (SATA)
Obtain an informed consent from the pation or family member Review results for diagnostic tests, including CBC, ABO group, Rh compatability, Urinalysis Explanation: Surgery
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. Whu, the nurse woulf push the presenting part off the cord to relieve the compression. Position changes to relieve cpmpression: knee-to-chest, trendelenburg, hips higher than chest, modified Sims
Carla Hernandez was in active labor when the umbilical cord prolapse was identified. The provider ordered a tocolytic agent to relax the uterine smooth muscle. What is the best route for administering terbutaline sulfate to the patient in this situation?
Subcutaneous, back of arm
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 impoved 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
During the initial assessment for Carla Hernandez, there was bradycardia, late decelerations, and minimal variability. The nurse could determine that measures to relieve umbilical cord compression were successful by which of the following evaluative findings? (select all that apply)
long-term variability was 10 to 15 beats per minute The umbilical cord had a pulse The umbilical cord had a pH of 7.3 and maternal oxygen saturation was at 98%
The nurse monitors for adverse effects from terbutaline sulfate, which was given to Carla Hernandez after umbilical cord prolapse was identified. Which of the following are signs of adverse effects of this drug? (select all that apply)
maternal heart rate 154, regular maternal blood pressure 152/94 mm Hg auscultate crackles throughout the lungs
