Maternity Nursing: Intrapartum Q 12
A nurse in the labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following would be the initial nursing action?
A. Place the client in Trendelenburg’s position.
B. Call the delivery room to notify the staff that the client will be transported immediately.
C. Gently push the cord into the vagina.
D. Find the closest telephone and stat page the physician.
Correct Answer: A. Place the client in Trendelenburg’s position.
When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. Oxygen at 8 to 10 L/min by face mask is delivered to the mother to increase fetal oxygenation.
Option B: The definitive management of umbilical cord prolapse is expedient delivery; this is usually by cesarean section. In rare cases, vaginal delivery or operative vaginal delivery may be faster and, thus, preferable, but this should only occur under the presence and guidance of an experienced obstetrician.
Option C: No attempt should be made to replace the cord. The examiner, however, may place a gloved hand into the vagina and hold the presenting part off of the umbilical cord. Decompression should be done manually by the medical provider through the placement of their finger or hand in the vaginal vault and gentle elevation of the presenting part off the umbilical cord. The provider should be conscientious not to place any additional pressure on the cord, as this can cause vasospasm and worsen outcomes.
Option D: The nurse should push the call light to summon help, and other staff members should call the physician and notify the delivery room. If the cord is visibly protruding from the introitus, it should remain warm and moist because the ambient temperature is significantly colder than the temperature in the uterus and can result in vasospasm of the umbilical arteries, contributing to fetal hypoxia. One method described preventing this is the replacement of the cord into the vaginal vault followed by insertion of a moist tampon to keep it in place.