The nurse is caring for a client experiencing variable decelerations. The nurse observes the umbilical cord protruding through the vagina.
Place the following actions in the order in which they should be performed, starting from first to last.
The nurse is caring for a client experiencing variable decelerations. The nurse observes the umbilical cord protruding through the vagina.
Place the following actions in the order in which they should be performed, starting from first to last.
Correct Answer is:
Statistics
Subject/Lesson
Subject
Maternal & Newborn Health
Lesson
Labor/Delivery
Client Need
Test Plan
Health Promotion and Maintenance
Related Topic
Ante/Intra/Postpartum and Newborn Care
Item Type
Item Type
Application
Explanation
1. Activate the obstetric emergency response and call for assistance.
Umbilical cord prolapse is an obstetric emergency that requires immediate help from the interdisciplinary team. Additional staff are needed because several interventions must occur while one nurse remains at the bedside and maintains continuous elevation of the presenting fetal part.
2. Use a sterile-gloved hand to lift the presenting fetal part off the umbilical cord and maintain continuous elevation.
Manual elevation relieves compression of the prolapsed cord and helps restore fetal blood flow. Once the nurse begins this intervention, the nurse must maintain elevation continuously until birth or until another effective method of decompression is established.
3. Direct an assisting nurse to place the client in the knee–chest or Trendelenburg position.
A gravity-assisted position helps move the presenting fetal part away from the umbilical cord and further reduces cord compression. An assisting nurse performs the position change because the nurse providing manual elevation cannot remove the hand or leave the client.
4. Direct an assisting nurse to administer oxygen by face mask according to the emergency protocol.
Supplemental oxygen may be administered according to agency protocol to support maternal and fetal oxygenation during the emergency. Another nurse applies the oxygen equipment while manual elevation of the presenting fetal part continues.
5. Prepare the client for immediate birth while manual elevation continues.
Expedited birth is the definitive treatment because temporary decompression measures do not correct the underlying cord prolapse. The health care team prepares for emergency birth while the nurse continues lifting the presenting fetal part off the cord.
Related Videos
8 Key Topics
Disease Specific Positioning
9.14 Disease-Specific Positioning
Decelerations
29.1 Fetal Monitoring Basics
Nursing Interventions for Nonreassuring
29.2 Interpretation & Nursing Response
Prolapsed Umbilical Cord
30.4 Intrapartum Complications
Additional Info
source: Archer Review
Source : source: Archer Review
✓ Variable decelerations suggest an interruption of oxygenation at the level of the umbilical cord, where cord vessels may be compressed.
✓ Physiologically, the thin-walled umbilical vein is occluded during umbilical cord compression in umbilical cord prolapse or oligohydramnios.
✓ The nurse should execute actions immediately, such as summoning help and relieving pressure off the umbilical cord.
✓ Having the client reposition is essential; the nurse may have the client assume positions such as knee-chest position, Trendelenburg position, and hips elevated with pillows, with side-lying position maintained.
