The nurse is caring for a client in labor experiencing a prolapsed umbilical cord. The nurse anticipates that the fetal heart rate pattern will likely show
The nurse is caring for a client in labor experiencing a prolapsed umbilical cord. The nurse anticipates that the fetal heart rate pattern will likely show
A. early decelerations.
[7%]
B. variable decelerations.
[57%]
C. late decelerations.
[35%]
D. normal variability.
[1%]
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
Analysis
Explanation
Choice B is correct. A prolapsed umbilical cord is a serious finding that may lead to fetal hypoxia. The nurse must act quickly if this is suspected. Common fetal heart rate patterns observed during a prolapsed umbilical cord include variable decelerations, sustained bradycardia, or prolonged decelerations. All of these patterns are non-reassuring.
Choice A is incorrect. Early decelerations are benign and are consistent with a vaginal response during fetal head compression.
Choice C is incorrect. Late decelerations are non-reassuring and are associated with compression of the maternal inferior vena cava.
Choice D is incorrect. Normal variability would not be expected with a prolapsed umbilical cord.
Related Videos
6 Key Topics
Disease Specific Positioning
9.14 Disease-Specific Positioning
Decelerations
29.1 Fetal Monitoring Basics
Prolapsed Umbilical Cord
30.4 Intrapartum Complications
Additional Info
✓ A prolapsed umbilical cord is a medical emergency
✓ The prolapse may be hidden or complete
✓ This condition should be suspected if the fetal heart monitor shows sustained bradycardia, variable decelerations or prolonged deceleration
✓ The nurse should reposition the client with the intent to position the woman’s hips higher than her head to shift the fetal presenting part
✓ Acceptable positions include knee-chest, Trendelenburg, or hips elevated with pillows, with side-lying position maintained
✓ The nurse should shout for help, pause oxytocin infusion, and provide oxygen via face mask at 8-10 liters/minute
✓ Provide and maintain vaginal elevation of the presenting part using a gloved hand
✓ An emergency cesarean section is likely
