A registered nurse is caring for a gravid client in active labor when spontaneous rupture of membranes occurs. The fetal heart rate suddenly drops to , and the nurse visualizes the umbilical cord protruding from the introitus. In what sequence should the nurse perform the following actions? Arrange the interventions from first to last.
- 1Call for immediate assistance from other staff members.
- 2Insert a sterile, gloved hand into the vagina to apply upward pressure on the fetal presenting part.
- 3Assist the client into a knee-chest or extreme Trendelenburg position.
- 4Administer oxygen to the client at via a nonrebreather face mask.
- 5Prepare the client for an immediate cesarean birth.
Answer
The correct sequence for managing an umbilical cord prolapse is to first call for assistance, followed immediately by manually elevating the fetal presenting part off the cord. Next, the client should be repositioned into a knee-chest or Trendelenburg position, followed by the administration of oxygen, and finally, preparing the client for an emergency cesarean birth.
The priority in an umbilical cord prolapse is to restore fetal oxygenation while preparing for rapid delivery. The nurse must first call for help to mobilize the surgical team. Instantly following this, the nurse must manually elevate the presenting part to remove life-threatening pressure from the cord. Maternal repositioning utilizes gravity to sustain this relief. Providing high-flow oxygen treats the systemic fetal hypoxia. Finally, preparing for surgical delivery serves as the ultimate resolution to the emergency.
Step-by-Step Solution
Key Concept
Prioritization of care in obstetrical emergencies (Umbilical Cord Prolapse)