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Difficulty: MediumAnte/Intra/Postpartum and Newborn Care

A nurse is evaluating a client at 40 weeks of gestation who is in active labor. Shortly after the spontaneous rupture of membranes, the electronic fetal monitor displays sudden, severe variable decelerations. During a subsequent vaginal examination, the nurse palpates a soft, pulsating mass in the vaginal vault. Which of the following actions should the nurse take immediately?

  1. A
    Place the client in a high-Fowler's position to facilitate fetal engagement.
  2. B
    Instruct the unlicensed assistive personnel (UAP) to monitor the fetal heart rate.
  3. Use a sterile, gloved hand to elevate the fetal presenting part off the umbilical cord.Answer
  4. D
    Prepare to administer an intravenous tocolytic medication to reduce uterine contractions.

Answer

The correct action is to use a sterile, gloved hand to manually elevate the fetal presenting part off the umbilical cord.
The clinical scenario describes an umbilical cord prolapse, a life-threatening obstetric emergency where the umbilical cord slips ahead of the fetal presenting part and becomes compressed. This causes severe variable decelerations and fetal hypoxia. The immediate, life-saving priority is to physically relieve the pressure on the cord to restore fetal blood flow. The nurse must insert a sterile, gloved hand into the vagina and apply continuous upward pressure on the fetal presenting part until an emergency cesarean birth can be performed.

Step-by-Step Solution

1
Identify the clinical emergency from the assessment findings.
The presence of a pulsating mass in the vagina combined with severe variable decelerations following the rupture of membranes indicates an umbilical cord prolapse.
Accurate recognition of the complication is required to determine the appropriate life-saving intervention.
2
Determine the physiological consequence of the complication.
The fetal presenting part is physically compressing the umbilical cord against the maternal pelvis, cutting off the oxygen and blood supply to the fetus.
Understanding the pathophysiology guides the nurse toward the correct physical intervention.
3
Select the immediate priority nursing intervention.
The nurse must manually elevate the presenting part off the umbilical cord and maintain this upward pressure.
This mechanical action immediately relieves cord compression and restores fetal oxygenation while the team prepares for an emergency cesarean birth.

Key Concept

Management of Umbilical Cord Prolapse
Estimated Time:1m 0s
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Topics

Ante/Intra/Postpartum and Newborn Care

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