The first thing the nurse should ensure when the baby's head comes out is?

WCL Staff Nurse - 2019

Obstetrics & Gynaecology

Medium

Appeared in: WCL Staff Nurse - 2019

Explanation

The immediate priority after the head is delivered is to check for a nuchal cord (umbilical cord wrapped around the neck).
This is done by sliding a finger along the fetal neck to feel for the cord.
A tight nuchal cord can compress the umbilical vessels during the final stages of delivery, leading to fetal hypoxia and bradycardia.
Prompt identification allows the nurse or provider to manage it by either slipping it over the head or clamping and cutting it to allow for a safe delivery.

Option A: While an intact cord is essential for fetal oxygenation, it is not the most immediate action to perform. The primary concern at this moment is the mechanical risk of compression from a nuchal cord, which can quickly lead to fetal distress.
Option C: The cord being attached to the placenta is the normal physiological state and is necessary for the baby to receive oxygen until birth is complete. It is not something the nurse needs to actively 'ensure' at this specific moment.
Option D: Assessing for cord pulsations is a way to check for fetal well-being, but it is a secondary assessment. The primary action is to identify and relieve any potential obstruction, like a nuchal cord, which is the very thing that could cause the pulsations to stop.

Clinical Relevance

Nursing practice connection: Knowing Management of the second stage of labor, specifically the immediate actions after the delivery of the fetal head helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
Nurses play a critical role in assisting with delivery and must be prepared for common complications like a nuchal cord, which occurs in nearly 25% of term deliveries.
Being prepared with two sterile cord clamps and scissors on the delivery trolley is a key nursing responsibility for managing a tight nuchal cord.
What if? If the nuchal cord is too tight to slip over the head, the standard procedure is to clamp the cord in two places and cut between the clamps before delivering the shoulders. This prevents avulsion of the cord or placenta and relieves compression on the fetal neck.

How to Approach the Question

Identify the question type: This is a priority-based question asking for the 'first' action in a specific clinical scenario (delivery of the fetal head).
Analyze the scenario: The baby's head is out, but the body is not yet delivered. The baby is still dependent on the umbilical cord for oxygen.
Evaluate the options based on immediate risk: Consider which option addresses the most immediate, life-threatening problem that can occur in this specific timeframe.
Option A (intact): Important, but not the immediate action.
Option B (nuchal cord): A tight cord is an immediate threat to oxygen supply. This is a high-priority check.
Option C (attached to placenta): This is the normal, expected state.

Concept Tested & Keywords

Concept Tested: Management of the second stage of labor, specifically the immediate actions after the delivery of the fetal head.
Stem keywords: baby's head comes out, first thing, nurse should ensure
Lead-in keywords: first thing

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E6 Obstetrics Williams p. 5-14

E6 Midwifery Obstetrics and Gynecology Nursing Sandeep Kaur p. 58-72