QUESTION: "Umbilical cord prolapse occurs after spontaneous rupture of the membranes. Which of the following should the nurse do immediately?"
CHOICES
( O ) a.) Place the client in a Trendelenburg position.
( X ) b.) Administer oxytocin intravenously.
( X ) c.) Ask the client to begin pushing.
( X ) d.) Cover the cord with sterile towels.
RATIONALE: The first step in managing a cord prolapse is to relieve pressure on the cord. Immediate measures include lowering the client's head by using the Trendelenburg position or knee-to-chest position so that the fetal presenting part will move away from the pelvis and moving the fetal presenting part off the cord by applying pressure through the vagina with a sterile gloved hand. An immediate cesarean delivery is usually performed. Oxytocin would not be given because the drug stimulates uterine contractions, putting further pressure on the cord as the contractions attempt to expel the fetus. Pushing results in further cord compression and decreased fetal heart rate. With cord prolapse, an immediate cesarean delivery is indicated. There is no need to cover the cord to avoid damage or tearing. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
