For the client with an NG tube who begins vomiting, the nurse should check the tube placement because it might be displaced, thereby leading to vomiting. The other responses are not appropriate.
Reduction of Risk Potential

Section: Physiological Integrity
Explanation:
Prolapsed umbilical cord is the descent of the umbilical cord into the vagina before the fetal presenting part and compression of the cord between the presenting part and the maternal pelvis, compromising or completely cutting off fetoplacental perfusion.
This is an emergency situation; immediate delivery should be attempted to save the fetus.

Gagging during the gag reflex test indicates that cranial nerves IX and X (the glossopharyngeal and vagus nerves) are intact.Health Promotion and Maintenance

Section: Health Promotion and Maintenance
Explanation:
Glucose is monitored closely when a client is on total parenteral nutrition, due to high glucose concentration in the solutions. The other values are not monitored as closely.

Muscle weakness in the lower extremities is found in acute cases of Guillain-Barre' Syndrome.