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 client in McRoberts position.
2. Watch for the emergence of the placenta.
3. Prepare for the delivery of an undiagnosed twin.
4. Place the client in a supine position.
2
Explanation: 2. Signs of placental separation usually appear around 5 minutes after birth of the infant, but can take up to 30 minutes to manifest. These signs are (1 ) a globular-shaped uterus, (2 ) a rise of the fundus in the abdomen, (3 ) a sudden gush or trickle of blood, and (4 ) further protrusion of the umbilical cord out of the vagina.
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