A pregnant client tells the nurse that she felt wetness on her peripad and found some clear fluid. The nurse immediately inspects the perineum and notes the presence of the umbilical cord. The nurse's initial action is?

1. A

   Notify the physician

2. B

   Monitor the fetal heart rate

3. C

   Transfer the client to the delivery room

4. D

   Place the client in the Trendelenburg position

Appeared in: DHS Staff Nurse - 2018 (Shift-2nd)

Explanation

• The clinical presentation of a visible umbilical cord after rupture of membranes indicates a prolapsed cord, a critical obstetric emergency.
• The primary danger is compression of the cord between the fetus and the maternal pelvis, which obstructs blood flow and leads to severe fetal hypoxia.
• The immediate, highest-priority nursing action is to relieve this pressure to restore oxygenation to the fetus.
• Placing the client in a Trendelenburg (head down, feet up) or knee-chest position utilizes gravity to shift the fetus superiorly, away from the pelvic inlet, thus decompressing the cord.
• This intervention is the fastest and most effective initial step to prevent irreversible fetal harm or death.

Why Other Options Were Wrong

• Option A: Notifying the physician is a crucial step, but it is not the first action. The nurse must first perform an immediate life-saving intervention to protect the fetus.
• Option B: Monitoring the fetal heart rate is an assessment, not an intervention. In an emergency like a prolapsed cord, an immediate action to resolve the problem is the priority over assessment.
• Option C: Transferring the client to the delivery room is necessary for the birth, but it is not the initial action. Moving the client without first relieving pressure on the cord can worsen the compression and fetal distress.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Management of Obstetric Emergencies: Prolapsed Umbilical Cord to guide bedside assessment, documentation, and the next nursing action.
• A prolapsed umbilical cord is a time-critical emergency where the nurse's prompt and correct initial action directly determines the fetal outcome, preventing potential brain damage or death from hypoxia.
• The nurse must act immediately and confidently. Key actions are to relieve pressure and call for help. The nurse should never attempt to push the cord back into the uterus.
• Covering the exposed cord with a sterile, warm, saline-soaked dressing is also important to prevent drying and vasospasm.

How to Approach the Question

• First, identify the clinical problem from the stem. The key finding is 'the presence of the umbilical cord' after the client felt 'wetness' (rupture of membranes). This is the classic definition of an overt umbilical cord prolapse.
• Recognize the urgency of the situation. A prolapsed cord is a life-threatening emergency for the fetus due to cord compression and subsequent hypoxia.
• Apply the nursing principle of prioritizing interventions over assessments in a life-threatening situation. The core problem is pressure on the cord, so the priority is to relieve that pressure.
• Evaluate the given options to determine which one provides the most immediate and direct solution to the problem.
• Analyze the choices: Notifying the physician, monitoring FHR, and transferring to the delivery room are all necessary steps, but they are secondary to the immediate, life-saving action of relieving cord compression.
• Conclude that placing the client in the Trendelenburg position is the correct initial action as it uses gravity to directly and immediately address the life-threatening cord compression.

Concept Tested & Keywords

• Concept Tested: Management of Obstetric Emergencies: Prolapsed Umbilical Cord
• Stem keywords: pregnant client, wetness, clear fluid, presence of the umbilical cord, initial action
• Lead-in keywords: initial action
• Clinical cues: The presence of the umbilical cord at the perineum after reported rupture of membranes is the classic sign of an overt umbilical cord prolapse.

Question ID

qj2wPv4YU0DrxJ0t-bi7G

Copy ID

Reference Book

E6 Midwifery Obstetrics and Gynecology Nursing Sandeep Kaur p. 9-14