A nurse is performing a sterile vaginal examination on a client in active labor who has just experienced a spontaneous rupture of membranes. The nurse palpates a soft, pulsating mass in the vaginal vault. The electronic fetal monitor demonstrates severe, recurrent variable decelerations. Arrange the following nursing actions in the priority order they should be performed.
- 1Keep the examining fingers in the vagina and apply upward firm pressure to the fetal presenting part.
- 2Direct another staff member to call for emergency assistance and notify the healthcare provider.
- 3Assist the client into a knee-chest or extreme Trendelenburg position.
- 4Administer supplemental oxygen at 8 to 10 L/min via a nonrebreather face mask.
- 5Prepare the client and equipment for an immediate emergency cesarean birth.
Answer
The correct sequence of actions is: 1. Apply upward pressure to the fetal presenting part, 2. Call for emergency assistance, 3. Reposition into a knee-chest or Trendelenburg position, 4. Administer oxygen, 5. Prepare for emergency cesarean birth.
Umbilical cord prolapse is an acute, life-threatening obstetric emergency characterized by the cord slipping ahead of the fetal presenting part. The overarching goal is to prevent fetal hypoxia. The nurse must first manually relieve cord compression (the immediate physiological threat). While maintaining this pressure, the nurse secures help. Repositioning utilizes gravity to assist. Oxygen is then administered to optimize fetal oxygenation before preparing for the definitive surgical delivery.
Step-by-Step Solution
Key Concept
Nursing management and prioritization for umbilical cord prolapse