As the nurse prepares a client for a vaginal examination, a loop of pulsating umbilical cord is observed at the vaginal introitus. What is the priority nursing action?
a. Listen for the fetal heart tones with a Doppler device or electronic fetal monitor.
b. Perform a vaginal exam, and elevate the presenting part of the cord.
c. Prepare her for immediate cesarean delivery.
d. Put on a sterile glove and gently reinsert the cord into the vaginal opening.
B
The priority with a prolapsed cord is to decrease the pressure on the cord as soon as possible. Listening for the fetal heart tones with a Doppler device or electronic fetal monitor and preparing her for immediate cesarean delivery are important interventions, but they are not the highest priority. Putting on a sterile glove and gently reinserting the cord into the vaginal opening may increase the pressure on the cord and further compromise the fetus.
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