A nurse is assisting with the care of 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 take first?
A.
Prepare the client for an emergency cesarean birth.
B.
Explain to the client what is happening.
C.
Cover the cord with a sterile, moist saline dressing.
D.
Place the client in a knee-chest or Trendelenburg position.
The correct answer and Explanation is :
In this scenario, the correct action for the nurse to take first is:
D. Place the client in a knee-chest or Trendelenburg position.
Explanation:
The observation of the umbilical cord protruding from the vagina is indicative of a condition known as a prolapsed umbilical cord. This occurs when the cord slips ahead of the presenting part of the fetus, potentially leading to compression of the cord and impaired fetal oxygenation. The primary concern with a prolapsed cord is that it can lead to cord compression, which in turn can cause fetal hypoxia (lack of oxygen) and distress.
Here’s why placing the client in a knee-chest or Trendelenburg position is the most critical first step:
- Relieves Pressure on the Cord: By positioning the client in a knee-chest position or Trendelenburg position (where the head is lower than the feet), gravity helps to move the fetus away from the umbilical cord, reducing the pressure on the cord. This action can temporarily alleviate cord compression and improve blood flow and oxygenation to the fetus.
- Immediate Intervention: This positioning is a rapid intervention that can help prevent or mitigate potential fetal distress. It is essential to act quickly to ensure the fetus receives adequate oxygen.
- Prioritizing Fetal Well-being: The safety and well-being of the fetus are the highest priorities. Immediate actions to relieve cord compression are crucial before proceeding with other interventions.
Once the initial step of positioning the client is taken, the nurse can then proceed with other necessary actions:
- C. Cover the cord with a sterile, moist saline dressing: This helps to protect the exposed cord from drying out and potential infection. However, this is not the immediate priority compared to relieving cord compression.
- A. Prepare the client for an emergency cesarean birth: While this may eventually be necessary if the fetal distress persists or worsens, it is not the first step. Immediate positioning to relieve cord compression takes precedence.
- B. Explain to the client what is happening: While communication is important, the immediate focus should be on addressing the physical issue affecting the fetus. Explanation can be done after taking the necessary actions to stabilize the situation.
In summary, placing the client in a knee-chest or Trendelenburg position is the first and most critical action to address a prolapsed umbilical cord, as it directly impacts the well-being of the fetus.