A nurse is caring for a laboring client when the membranes rupture and a prolapsed umbilical cord is identified. The fetal heart rate drops from 140 bpm to 80 bpm. What is the nurse's immediate priority action?
During active labor, a client's membranes rupture spontaneously, and the nurse observes the umbilical cord protruding from the vagina. The fetal heart rate drops from 140 bpm to 80 bpm.
1Call the healthcare provider immediately and prepare for emergency cesarean section
2Position the client in knee-chest or Trendelenburg position and apply moist sterile gauze to the cord✓ 정답
3Administer oxygen at 10 L/min via face mask and start IV fluids
4Push the cord back into the vagina gently to relieve compression
해설
The immediate priority is to relieve cord compression by positioning the client in knee-chest or Trendelenburg position and applying moist sterile gauze to the cord. This directly addresses fetal bradycardia and hypoxia, while other actions are supportive or contraindicated.
Core Nursing ExplanationKey Concept Analysis: This question tests the immediate nursing response to a prolapsed umbilical cord, a true obstetric emergency. The pathophysiological mechanism is cord compression. When the cord prolapses ahead of the presenting part (especially after rupture of membranes (ROM)), it gets compressed between the fetal part and the maternal pelvis or vaginal wall. This compresses the umbilical vessels, drastically reducing blood flow and oxygen delivery to the fetus, leading to fetal bradycardia (a drop from 140 to 80 bpm). The priority is to Key Point!relieve the compression immediately to restore fetal oxygenation.
Answer Rationale: The correct action is Position the client in knee-chest or Trendelenburg position and apply moist sterile gauze to the cord. This is the gold-standard, first-line intervention. The knee-chest position or Trendelenburg position uses gravity to shift the presenting part (usually the fetal head) away from the pelvis, relieving pressure on the cord. Applying moist sterile gauze prevents the cord from drying out (which causes vasoconstriction) and minimizes the risk of infection. This action directly and immediately addresses the cause of the fetal bradycardia.
Distractor Analysis:
Watch out for confusion! Option ① (Call provider, prepare for C-section): While an emergency cesarean section is the definitive treatment, it is not the nurse's immediate action. The nurse must first perform life-saving measures to relieve cord compression while someone else calls the provider and prepares for surgery. Acting on option ① first wastes critical minutes.
Option ③ (Administer O2, start IV): These are important supportive measures but do not address the root cause—mechanical compression of the cord. They would be done concurrently or immediately after positioning the client, not as the first priority.
Option ④ (Push cord back): This is contraindicated. Attempting to push the cord back can cause vasospasm, further compromising blood flow, and increases the risk of infection. The cord should never be manipulated back into the uterus.
Related Concepts: This scenario requires understanding the nursing process in an emergency: Assessment (identifying prolapse and bradycardia) leads to the nursing diagnosis of Ineffective fetal tissue perfusion. The planning and implementation are focused on the single, immediate goal of relieving compression. Evaluation involves continuous fetal heart rate (FHR) monitoring for improvement.
Concept Summary
Concept
Key Points
Prolapsed Cord
Umbilical cord presents ahead of the fetal presenting part after ROM. A true emergency due to risk of cord compression and fetal hypoxia.
Immediate Nursing Priority
Relieve compression. Position mother (knee-chest/Trendelenburg). Apply moist sterile cover to cord.
Fetal Response
Variable decelerations or prolonged bradycardia (as in this case) on the fetal monitor.
Definitive Treatment
Emergency cesarean delivery.
Nursing Actions (Concurrent)
Call for help, notify provider, administer O2 via non-rebreather mask, start IV, prepare for surgery, provide emotional support.
Side-by-Side Comparison!
Obstetric Emergency
Primary Mechanism
Key Nursing Intervention
Prolapsed Cord
Mechanical compression of cord
Position to relieve pressure (knee-chest). Cover cord with moist sterile gauze.
Placental Abruption
Premature separation of placenta
Monitor for concealed hemorrhage, shock, fetal distress. Prepare for emergency delivery.
Uterine Rupture
Tearing of uterine wall
Recognize signs (sudden pain, loss of fetal station, maternal shock). Prepare for immediate laparotomy.
Amniotic Fluid Embolism
Anaphylactoid reaction to amniotic fluid
Manage cardiopulmonary collapse (ABCs), administer O2, fluids, inotropic support. Prepare for emergency delivery.
Anatomy, Physiology & Pharmacology Points
Physiology: The umbilical cord contains two arteries and one vein, transporting oxygenated blood to the fetus (via the vein) and deoxygenated blood away (via the arteries). Compression obstructs this flow.
Fetal Heart Rate (FHR): A normal FHR is 110-160 bpm. A drop to 80 bpm indicates severe fetal compromise (bradycardia) due to hypoxia.
Positioning Physiology: The knee-chest position (on hands and knees with chest down) or Trendelenburg (head down) uses gravity to pull the fetal presenting part upward and out of the pelvis.
Memory Tips
Acronym: P.R.E.S.S. for Prolapsed Cord Management:
Position (Knee-chest/Trendelenburg)
Relieve pressure (Goal of positioning)
Elevate presenting part
Sterile moist cover (Gauze)
Support (O2, IV, call for help)
Never Push! Remember: You cover the cord, you don't shove it back in.
High-Frequency NCLEX Topics
Prolapsed cord is a classic NCLEX priority question. The exam tests your ability to sequence actions correctly in an emergency. Remember: Your first action is always the one that directly treats the life-threatening problem (relieving compression), not calling the doctor or preparing for a procedure. Supportive care (O2, IV) comes next, and definitive care (surgery) follows.
Watch Out for Question Variations!
The same concept can be tested in different ways:
Symptom Identification: "The nurse observes a loop of cord in the vagina after ROM. What should the nurse do first?"
Positioning Specifics: "Which position is most appropriate for a client with a prolapsed cord?" (Knee-chest is best; Sims' or side-lying may be distractors).
Evaluation: "After positioning a client with a prolapsed cord, which finding indicates the intervention is effective?" (Answer: FHR returns to normal baseline).
Nursing Clinical Practice GuideClinical Scenario: You are the labor nurse for Maria, a 38-week G2P1 patient. Her membranes rupture spontaneously. During your assessment, you see a loop of umbilical cord protruding from her vagina. You place her on the external fetal monitor, and the FHR, which was 140, suddenly drops to 80 bpm. Maria is anxious and asking what's happening.
Nursing Intervention Strategy:
Immediate Action (Do this yourself while calling out): Shout for help! Without leaving the bedside, use the bed controls to put Maria into a steep Trendelenburg position. If that's not possible, quickly help her assume the knee-chest position on the bed. With a sterile glove, gently cover the protruding cord with sterile saline-soaked gauze from your delivery tray. Do not hold or push the cord.
Delegate & Communicate: As you are positioning Maria, instruct another nurse or aide who has entered the room to: a) Call the obstetrician/CNM and anesthesia stat, b) Call the OR to prepare for an emergency cesarean section, c) Bring the emergency crash cart to the room.
Concurrent Supportive Care: Apply a non-rebreather oxygen mask at 10-15 L/min to maximize maternal-fetal oxygenation. Start a large-bore IV line if not already present, and run isotonic fluids (e.g., Lactated Ringer's). Continuously monitor the FHR for improvement.
Preparation for Surgery: While maintaining the relieving position, quickly explain the situation to Maria and her partner. Obtain informed consent for surgery. The team will transfer her to the OR while she remains in the Trendelenburg position, often with a nurse's hand maintaining gentle upward pressure on the presenting part (via the vagina) during transfer.
Patient Safety and Precautions:
Contraindication: Never attempt a vaginal exam if a prolapsed cord is suspected or confirmed, as this may worsen compression.
Cord Handling: Keep the cord moist with sterile normal saline. Do not use antiseptic solutions or attempt to warm the cord excessively.
Monitoring: The goal is to see the FHR return to baseline. If bradycardia persists despite positioning, prepare for the most expedient delivery possible.
Nursing Procedure & Medication FlowProcedure: Managing a Prolapsed Cord
1. Recognize: Identify cord in vagina after ROM + FHR changes.
2. Relieve: Position client (knee-chest/Trendelenburg).
3. Cover: Apply moist, sterile gauze to cord.
4. Call: Activate emergency response (Provider, OR, Anesthesia).
5. Support: Administer O2, establish IV access.
6. Prepare: Explain, obtain consent, prepare for emergency C-section.
7. Transfer: Maintain relieving position during transport to OR.
Medication Note: Tocolytics (like terbutaline) are sometimes used in this scenario to relax the uterus and further reduce pressure on the cord, but this is a physician order. The nurse's independent actions are positioning and cord care.
A Word from Your Senior Nurse
"In the chaos of an obstetric emergency, your calm, decisive action is what saves lives. For a prolapsed cord, your hands moving to position the mother are more critical in that moment than your voice calling for help. Muscle memory from studying these scenarios is key. In clinicals and on the NCLEX, always ask yourself: 'What is physically killing the patient (or fetus) right now, and what can I do in the next 30 seconds to stop it?' That's how you find your priority action. You've got this!"
Prolapsed Umbilical Cord — A true obstetric emergency where the umbilical cord descends through the cervix into the vagina ahead of the fetal presenting part, especially after rupture of membranes, risking compression and fetal hypoxia.
Knee-Chest Position — A position where the patient is on hands and knees with chest lowered to the bed, used in prolapsed cord to use gravity to shift the fetal presenting part away from the pelvis and relieve cord compression.
Fetal Bradycardia — A fetal heart rate (FHR) below 110 beats per minute (bpm). A sudden, profound bradycardia (e.g., drop to 80 bpm) is a sign of acute, severe fetal compromise, often from cord compression or placental abruption.
Trendelenburg Position — A position where the patient lies supine with the feet elevated higher than the head. Used as an alternative to knee-chest position for prolapsed cord to achieve the same goal of relieving pressure via gravity.
Rupture of Membranes — The breaking of the amniotic sac ("water breaking"). Spontaneous ROM (SROM) is a normal part of labor but is a risk factor for complications like prolapsed cord if the presenting part is not well-engaged.