Vsim Carla Hernandez Pre/Post-test
Post-test 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: Performed amniotomy is a risk factor for prolapsed umbilical cord prolapse.
Pre-test 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? (Select all that apply). Shave the abdomen to the pubic bone with a straight-edge razor Administer the ordered preoperative intravenous medications Review results for diagnostic tests, including complete blood count, blood type and crossmatch, and urinalysis Assess the intravenous site for patency and hang a full bag of IV fluids Obtain an informed consent from the patient or family member
Administer the ordered preoperative intravenous medications. Review results for diagnostic tests, including complete blood count, blood type and crossmatch, and urinalysis. Assess the intravenous site for patency and hang a full bag of IV fluids. Obtain an informed consent from the patient or family member.
Pre-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.
Post-test After the umbilical cord prolapse has been identified, which of the following personnel should the nurse inform of this emergency? (Select all that apply). Surgery Neonatal intensive care unit (NICU) Case manager Social worker Provider
NICU Surgery Provider
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 patient or family member Review results for diagnostic tests, including CBC, ABO group, Rh compatibility, Urinalysis Administer the ordered preoperative intravenous medications Assess the intravenous site for patency and hang a full bag of IV fluids Explanation: Surgery
Post-test To prepare for an immediate cesarean delivery for Carla Hernandez, what would the nurse do first?
Obtain an informed consent.
Pre-test 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.
Pre-test Arrange the answers into the correct order. Mouse users arrange by clicking and dragging each answer to the desired location. Keyboard users can arrange though drop down by selecting the right order. A laboring woman called the nurse to report her bag of waters 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 the interventions the nurse should perform.
Pre-test 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 a knee-chest position 4)Administer oxygen by nonrebreather 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 7)Document the actions and procedures taken to resolve this situation. Rationale: The nurse would immediately call for assistance and delegate to get the provider into the hospital and to prepare for an immediate cesarean delivery. The next priority is to reestablish blood flow through the umbilical cord by relieving the compression on the cord by the presenting part. Any position that gets the woman's hips higher than her chest would redirect the fetus back inside the uterus. To improve oxygenation to the fetus, a nonrebreather mask is applied at 8 to 10 L/min. The nurse keeps the patient and her support person informed of the measures that are being taken and the reason for these measures. The nurse would evaluate that these measures are working by interpreting the continuous fetal monitor for resolution of decreased fetal heart rate and nonreassuring periodic patterns. The last step is to document the care that was provided by noting the actions and procedures that were implemented.
Post-test 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
Post-test 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.
Pre-test 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? Select apply all that. Monitor the color, amount, and smell of the amniotic fluid Check the maternal temperature, heart rate, and blood pressure Push the exposed umbilical cord back into the open vagina Use a gloved hand to lift the presenting part off the cord Assess the exposed umbilical cord for color and pulsation
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 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.
Post-test 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.
Pre-test 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.
Post-test 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?
Pre-test The nurse is admitting a labor woman at 39 weeks gestation. Which of the following are risk factors for prolapsed umbilical cord. Select all that apply. 38 weeks' gestation; estimated fetal weight of 3,317 g (7 lb., 5 oz.) Estimated fetal weight of 2,400 g (5 lb., 1 oz.) Amniotic fluid 2,200 mL Amniotomy performed; station -2 Multiple gestation Left occiput posterior position; longitudinal lie
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 include the following" Low birth weight, being second twins, transverse lie, breech presentation, preterm labor (less than 37 weeks), Polyhydramnios (greater than 2,000 mL), amniotomy (especially when fetus is not engaged), premature rupture of the membranes, placenta previa, and a long cord.
Post-test 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.
Pre-test Which of the following statements is true concerning prolapsed umbilical cord?
It is an emergency that required 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.
Post-test 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). Fetal heart rate decelerated after the peak of a contraction. The umbilical cord had a pulse. Green-colored fluid came out of the vagina. Long-term variability was 10 to 15 bpm. The umbilical cord had a pH of 7.3 and maternal SPO2 was at 98%
Long-term variability was 10 to 15 bpm. The umbilical cord had a pulse. The umbilical cord had a pH of 7.3 and maternal oxygen saturation was at 98%.
Post-test 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). Auscultate crackles throughout lung fields Maternal heart rate 154, regular Active bowel sounds in four quadrants Maternal blood pressure 152/94 mm Hg Uterine contraction frequency of 2 minutes
Maternal heart rate 154, regular. Maternal blood pressure 152/94 mm Hg. Auscultate crackles throughout the lungs.
Pre-test 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.
