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Difficulty: MediumAnte/Intra/Postpartum and Newborn Care

A nurse is caring for a client in active labor whose membranes have just spontaneously ruptured. Upon visual inspection of the perineum, the nurse observes a portion of the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?

  1. A
    Direct a nursing assistant to evaluate the fetal heart rate continuously.
  2. B
    Notify the healthcare provider before implementing further interventions.
  3. Assist the client into a knee-chest position.Answer
  4. D
    Place the client in a supine position with the head of the bed entirely flat.

Answer

Assist the client into a knee-chest position.
The priority nursing action for a prolapsed umbilical cord is to immediately relieve pressure on the cord to prevent fetal hypoxia and potential death. Assisting the client into a knee-chest position utilizes gravity to shift the fetal presenting part away from the maternal pelvis and off the umbilical cord, maintaining fetal blood flow.

Step-by-Step Solution

1
Identify the obstetrical complication from the assessment findings.
A protruding umbilical cord after membrane rupture indicates an umbilical cord prolapse.
Recognizing the emergency determines the pathway of care.
2
Determine the primary physiological threat associated with this complication.
The fetal presenting part will compress the cord against the pelvis, rapidly cutting off fetal oxygen supply.
Understanding the mechanism of injury (compression) dictates the required physical intervention.
3
Select the immediate priority intervention that addresses the physiological threat.
Assisting the client into a knee-chest (or Trendelenburg) position is required.
Gravity causes the fetus to shift upward toward the maternal diaphragm, immediately relieving the life-threatening cord compression.

Key Concept

Umbilical Cord Prolapse Emergency Management
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Topics

Ante/Intra/Postpartum and Newborn Care

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