A nurse is caring for a client in labor with a prolapsed cord. What action should the nurse take?
A) Cover the cord prolapsed outside the vagina with a dry towel.
B) Place the client in the left lateral or supine position.
C) Notify the physician and prepare for resuscitation of the newborn.
D) Perform a sterile vaginal examination immediately.
C
Feedback:
If the client has a prolapsed cord, the nurse should notify the physician at once and prepare for resuscitation of the newborn. If the cord has prolapsed outside the vagina, it is covered with sterile towels moistened with warm, sterile normal saline to prevent drying and caking of the cord and fetal blood. The nurse should place the client in the Trendelenburg or knee–chest position as ordered to avoid compression of the cord. The left lateral or supine positions are not beneficial. The birth attendant or nurse must insert a sterile gloved hand into the vagina, not for a vaginal examination but to hold the fetal presenting part away from the cord. This ensures that fetal circulation is not cut off while the woman is prepared for an emergency cesarean delivery.
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