A nurse is caring for a laboring client when the membranes rupture spontaneously. Which assessment finding would indicate umbilical cord prolapse and require immediate intervention?
1Sudden onset of severe abdominal pain with a rigid, board-like uterus
2Visible or palpable cord at the vaginal introitus with sudden fetal bradycardia✓ 정답
3Sudden gush of amniotic fluid with greenish meconium staining
4Maternal hypotension with decreased urine output and tachycardia
해설
Visible or palpable cord at the vaginal introitus with sudden fetal bradycardia is the definitive sign of umbilical cord prolapse, requiring immediate intervention. Other options represent other obstetric complications not specific to cord prolapse.
Clinical Judgment
This question evaluates the Recognize Cues stage. Immediately after the spontaneous rupture of membranes, the nurse must identify signs of an immediate emergency: Umbilical Cord Prolapse. The key is connecting the direct evidence of a "prolapsed cord" with the resulting signs of "immediate fetal distress." Option 2 presents the objective symptom of a cord visible or palpable at the vaginal introitus, along with sudden fetal bradycardia due to cord compression, depicting the clearest situation requiring immediate intervention. The other options are more related to other obstetric complications (e.g., placental abruption, polyhydramnios, maternal shock) rather than cord prolapse.
Memory Tip
The keywords to remember cord prolapse are the "3 P's": Prolapse, Palpable cord, Precipitous bradycardia. Alternatively, you can memorize it as "SEE and SAVE the baby": Sudden bradycardia, Exposed cord at the introitus, Emergency response needed.
KR vs US
In Korea, when cord prolapse occurs, the knee-chest position is immediately assumed, and a 'manual cord reduction' may be attempted by inserting a hand into the vagina to push the presenting fetal part upward to relieve cord compression. In the US NGN/NCLEX, rather than this specific manual technique, the priority tends to emphasize immediately reporting to the physician, repositioning the mother to Trendelenburg or knee-chest position to prevent the presenting part from compressing the cord, and placing moist gauze in the vagina to gently push the cord up. In both settings, the ultimate goal is the fastest possible cesarean delivery.
Clinical Practice GuideImmediate actions upon membrane rupture: 1) Auscultate fetal heart sounds, 2) Perform a vaginal examination to check for cord prolapse or fetal part prolapse. If cord prolapse is suspected or confirmed: 1) Report immediately to the physician/midwife, 2) Position the mother in Trendelenburg or knee-chest position, 3) Do not push the cord back into the vagina; cover it with moist saline gauze to relieve compression and protect it, 4) Administer oxygen, 5) Instruct emergency preparation for cesarean section.CautionIn SATA (Select All That Apply) questions asking about "initial actions a nurse should take after cord prolapse," the option "Push the prolapsed cord back into the vagina" is generally not correct. This carries a risk of cord infection or further injury. The correct approach is to relieve compression. Also, do not confuse "normal findings after membrane rupture" with "emergency signs." A slight change in amniotic fluid color (e.g., light meconium) alone does not indicate immediate cord prolapse.
Umbilical Cord Prolapse — Umbilical cord prolapse. A life-threatening obstetric emergency in which, after the rupture of the amniotic membrane, the umbilical cord slips out through the vagina ahead of or alongside the presenting part of the fetus (e.g., head, buttocks), becoming compressed by the fetal weight or the cervix.
Fetal Bradycardia — Fetal bradycardia. A condition where the fetal heart rate is persistently below the baseline (generally less than 110 bpm). It is an important sign of acute hypoxia due to umbilical cord compression during cord prolapse.
Rupture of Membranes — Rupture of membranes. A condition during pregnancy where the amniotic sac surrounding the fetus breaks, causing amniotic fluid to leak. It can occur naturally or be artificially induced, and the timing and pattern (preceding/accompanying) of the rupture are important evaluation factors.
Vaginal Introitus — Vaginal opening. The external opening of the female reproductive system. When cord prolapse occurs, the prolapsed cord may be visible or palpable at this site, making it a point where direct assessment is possible.
Knee-Chest Position — Knee-chest position. This is an emergency position taken when umbilical cord prolapse occurs, where the mother places her knees and chest on the floor and elevates her hips. This position helps temporarily relieve cord compression by using gravity to move the fetus away from the pelvic inlet.