Physiological Adaptation Q 4
When assessing a laboring client, the nurse finds a prolapsed cord. The nurse should:
A. Attempt to replace the cord
B. Place the client on her left side
C. Elevate the client’s hips
D. Cover the cord with a dry, sterile gauze
Correct Answer: C. Elevate the client’s hips.
The client with a prolapsed cord should be treated by elevating the hips and covering the cord with a moist, sterile saline gauze. The nurse should use her fingers to push up on the presenting part until a cesarean section can be performed. Cesarean section should be performed before rupture of the membrane or the cord would slide down the vagina.
Option A: The nurse should not attempt to replace the cord. Assessment of fetal heart sounds is necessary after rupture of membranes to rule out cord prolapse. If there is already complete dilatation, the physician can deliver the baby to prevent fetal anoxia.
Option B: The client should not be turned to the side. The goal in therapeutic management is to relieve cord compression to avoid fetal anoxia that can be achieved through manually lifting the head of the fetal head off the cord through the vagina or placing the woman in a Trendelenburg position.
Option D: The cord should be covered with a moist, sterile saline gauze. Once the cord has prolapsed and is exposed to air, drying of the umbilical cord and atrophy of the umbilical vessels would begin. Cover any exposed portion of the cord with a sterile saline compress to avoid drying.