Four minutes after the birth of a baby, there is a sudden gush of blood from the mother's vagina and about 8 inches of umbilical cord slides out. What action should the nurse take first?
1. Place the bed in Trendelenburg position.
2. Watch for the emergence of the placenta.
3. Prepare for the delivery of an undiagnosed twin.
4. Roll her onto her left side.
2
Rationale 1: The Trendelenburg position is used for hypotensive patients.
Rationale 2: As the placenta separates from the uterine wall, the umbilical cord that extends out of the vagina lengthens, and a gush of blood occurs. Delivery of the placenta is the third stage of labor.
Rationale 3: The first placenta usually does not deliver before the birth of the second twin.
Rationale 4: Pregnant women are placed on the left side to facilitate uterine blood flow.
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