Free NCLEX-RN Exam Braindumps (page: 123)

Page 123 of 431

A laboring client presents with a prolapsed cord. The nurse should immediately place the client in what position?

  1. Reverse Trendelenburg
  2. Fowler's
  3. Trendelenburg
  4. Sims'

Answer(s): C

Explanation:

(A) Reverse Trendelenburg position increases pressure on the perineum. This position will not relieve cord pressure. (B) Fowler's position increases perineal pressure. Cord pressure would not be relieved. (C) Trendelenburg position will decrease perineal pressure. Cord compression will be decreased and increase in fetal blood flow occurs. (D) Sims' position does not relieve pressure on cord or perineum.



A laboring client presents with a prolapsed cord. The nurse should immediately place the client in what position?

  1. Reverse Trendelenburg
  2. Fowler's
  3. Trendelenburg
  4. Sims'

Answer(s): C

Explanation:

(A) Reverse Trendelenburg position increases pressure on the perineum. This position will not relieve cord pressure. (B) Fowler's position increases perineal pressure. Cord pressure would not be relieved. (C) Trendelenburg position will decrease perineal pressure. Cord compression will be decreased and increase in fetal blood flow occurs. (D) Sims' position does not relieve pressure on cord or perineum.



A nurse is performing a vaginal exam on a client in active
labor. An important landmark to assess during labor
and delivery are the ischial spines because:

  1. Ischial spines are the narrowest diameter of the pelvis
  2. Ischial spines are the widest diameter of the pelvis
  3. They represent the inlet of birth canal
  4. They measure pelvic floor

Answer(s): A

Explanation:

(A) The fetal descent, or station, is determined by the relationship of the presenting part to the spine. (B) Ischial spines are the narrowest measurement. (C) Ischial spines measure the pelvic outlet. (D) Pelvic floor measurement is not related to fetal descent.



A nurse is performing a vaginal exam on a client in active
labor. An important landmark to assess during labor
and delivery are the ischial spines because:

  1. Ischial spines are the narrowest diameter of the pelvis
  2. Ischial spines are the widest diameter of the pelvis
  3. They represent the inlet of birth canal
  4. They measure pelvic floor

Answer(s): A

Explanation:

(A) The fetal descent, or station, is determined by the relationship of the presenting part to the spine. (B) Ischial spines are the narrowest measurement. (C) Ischial spines measure the pelvic outlet. (D) Pelvic floor measurement is not related to fetal descent.



Page 123 of 431



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