A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?
A.
Insert a gloved hand into the vagina to relieve pressure on the cord.
B.
Cover the cord with a sterile, moist saline dressing.
C.
Place the client in knee-chest position.
D.
Prepare the client for an immediate birth.
The correct answer and Explanation is :
The correct answer is A. Insert a gloved hand into the vagina to relieve pressure on the cord.
Explanation:
When a nurse observes the umbilical cord protruding from the vagina during labor, this condition is known as a prolapsed umbilical cord. A prolapsed umbilical cord occurs when the cord slips ahead of the presenting part of the fetus, potentially compressing it and compromising oxygen supply. This is a critical situation that requires immediate intervention to prevent fetal distress.
Step-by-step Actions and Rationale:
- Relieve Pressure on the Cord (Option A): The first priority in managing a prolapsed umbilical cord is to relieve pressure on the cord to restore blood flow and oxygen to the fetus. By inserting a gloved hand into the vagina, the nurse can gently push the presenting part of the fetus off the cord, thereby reducing cord compression. This action is crucial to mitigate fetal distress and prevent potential hypoxia or other complications.
- Cover the Cord with a Sterile, Moist Saline Dressing (Option B): While it is important to cover the exposed cord to prevent it from drying out and reduce the risk of infection, this action should be performed only after the primary intervention to relieve cord compression has been taken. Moistening the cord with saline helps protect it and can be part of the subsequent care once the immediate pressure is alleviated.
- Place the Client in a Knee-Chest Position (Option C): The knee-chest position (or other positioning such as Trendelenburg) can also help relieve pressure on the cord by moving the fetus off the cord. However, immediate manual relief of pressure is often prioritized. Positioning changes are secondary interventions that can support the primary action of relieving pressure on the cord.
- Prepare for Immediate Birth (Option D): While preparation for an emergency birth might be necessary if the situation does not improve, the initial and most crucial step is to relieve cord compression to optimize the fetus’s condition before proceeding to prepare for a possible delivery.
In summary, Option A—inserting a gloved hand to relieve pressure—is the immediate and essential step in managing a prolapsed umbilical cord, aimed at preserving fetal well-being by alleviating compression on the cord.