# A 28-year-old gravida 1, para 0 client at 36 weeks gestation presents to the labor and delivery unit reporting intermittent leakage of clear fluid from her vagina since this morning. Which assessment finding would be the nurse's priority concern?

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> subject: Maternal Newborn Health

## 문제

A 28-year-old gravida 1, para 0 client at 36 weeks gestation presents to the labor and delivery unit reporting intermittent leakage of clear fluid from her vagina since this morning. Which assessment finding would be the nurse's priority concern?

## 보기

1. Maternal temperature of 100.4°F (38.0°C)
2. Fetal heart rate baseline of 140-150 beats per minute
3. Clear, odorless amniotic fluid on underwear
4. Umbilical cord palpable in the vaginal canal **✔ 정답**

**정답: 4**

## 해설

Umbilical cord palpable in the vaginal canal indicates cord prolapse, an obstetric emergency requiring immediate intervention to prevent fetal hypoxia. Other findings (mild fever, normal FHR, clear fluid) are less urgent.

## 심화 해설

Clinical Context and Priority Setting

A client at 36 weeks gestation presenting with intermittent leakage of clear fluid is experiencing premature rupture of membranes (PROM). While this condition carries several risks including infection and umbilical cord compression, the nurse must apply the ABC (Airway, Breathing, Circulation) priority framework, which in obstetric nursing extends to maternal and fetal well-being. When multiple concerning findings exist, the nurse must identify the finding that poses the most immediate threat to fetal life.

Analysis of Assessment Findings

Umbilical cord palpable in the vaginal canal indicates a cord prolapse, an obstetric emergency. When membranes rupture, if the presenting fetal part is not well-engaged in the pelvis, the umbilical cord can descend through the cervix into the vagina. This leads to compression of the umbilical vessels between the presenting part and the maternal pelvis, acutely interrupting fetal oxygenation. The fetal heart rate patterns described in the provided literature highlight that non-reassuring patterns are critical indicators of potential adverse fetal outcomes, and cord prolapse directly causes such patterns through variable or prolonged decelerations [1]. The velamentous cord insertion case report further emphasizes that unprotected umbilical vessels are at extreme risk during membrane rupture, as the cord lacks the protective Wharton's jelly when vessels traverse the membranes rather than inserting directly into the placenta [2]. Cord prolapse can rapidly progress to fetal hypoxia, hypoxic-ischemic encephalopathy (HIE), and perinatal death if not immediately relieved by elevating the presenting part and proceeding to emergency cesarean delivery. Research on HIE outcomes confirms that the severity of hypoxic insult directly correlates with adverse neurological outcomes, making immediate recognition and intervention critical .

Maternal temperature of 100.4°F (38.0°C) is a concerning sign suggesting chorioamnionitis, a bacterial infection of the amniotic membranes. The literature on neonatal sepsis identifies maternal infection as a significant risk factor for adverse neonatal outcomes . However, infection develops over hours to days, whereas cord compression causes fetal compromise within minutes. While maternal fever requires prompt antibiotic therapy and delivery planning, it does not take priority over an immediate threat to fetal circulation and oxygenation.

Fetal heart rate baseline of 140-150 beats per minute falls within the normal baseline range of 110-160 bpm. The study on non-reassuring fetal heart rate patterns identifies that a normal baseline does not exclude developing compromise, but this finding in isolation is reassuring rather than concerning [1]. The nurse should continue monitoring, but this is an expected finding, not a priority concern.

Clear, odorless amniotic fluid on underwear confirms membrane rupture, which is the precipitating event for the client's presentation. The fluid description is normal; amniotic fluid is typically clear and odorless. While this finding requires documentation and ongoing assessment for signs of infection or meconium staining, it represents the diagnosis rather than a new, emergent complication.

Pathophysiology and Clinical Reasoning

The priority hierarchy in this scenario follows the principle of addressing the most time-sensitive threat to fetal survival. Cord prolapse creates a mechanical obstruction to umbilical blood flow. The umbilical vein carries oxygenated blood from the placenta to the fetus, and the two umbilical arteries return deoxygenated blood. Compression occludes these vessels, leading to acute fetal hypoxemia, metabolic acidosis, and potentially irreversible brain injury. The HIE predictor study demonstrates that the duration and severity of hypoxic insult determine neurological outcomes, underscoring why every minute of cord compression matters . The nurse's immediate actions upon palpating a cord include positioning the client in knee-chest or Trendelenburg position, manually elevating the presenting part off the cord using a sterile gloved hand in the vagina, administering oxygen, and preparing for emergency cesarean delivery. These interventions directly address the circulatory obstruction, which aligns with the "Circulation" component of the ABC framework applied to fetal assessment.References (research sources)

- [1]Prevalence of non-reassuring fetal heart rate patterns and associated factors among labouring mothers at public hospitals in Wolaita Zone, Southern Ethiopia, 2024: A cross-sectional study.Research articleFiseha F, Assefa G, Tekalign T, Nima L, Kidane H, Alemu BM, Dadi HH, Ali YY, Tessema YN, Gebeyehu NA, Assfaw BB. (2026) · DOI: 10.1136/bmjopen-2025-109077

- [2]Velamentous Cord Insertion With Vaginal Delivery: A Case Report and Review of the Literature.Case reportMpourazanis G, Flindris S, Pantazis K, Alefragkis D, Papalexis P, Korkontzelos I, Kosmas I, Ntanasis A, Serra P, Laganà AS, Schulz-Wendtland R, Tsirkas P. (2026) · DOI: 10.7759/cureus.101487

## 임상 시나리오

Clinical Practice Guide: Immediate Management of Cord Prolapse

When a cord prolapse is identified, the nurse must act immediately to relieve pressure on the umbilical cord and prevent fetal hypoxia. The following steps outline the emergency response:

- **Call for Help:** Activate the obstetric emergency team and notify the provider immediately. Do not leave the patient.

- **Relieve Cord Compression:** Insert a sterile gloved hand into the vagina and gently elevate the presenting fetal part off the cord. Maintain this position until delivery.

- **Maternal Positioning:** Position the mother in Trendelenburg (head down) or knee-chest position to use gravity to reduce pressure on the cord.

- **Administer Oxygen and IV Fluids:** Provide high-flow oxygen via non-rebreather mask and increase IV fluid rate to improve fetal oxygenation and placental perfusion.

- **Monitor Fetal Heart Rate:** Continuously monitor for persistent bradycardia or non-reassuring patterns, which indicate ongoing distress and the need for emergent cesarean section.

- **Prepare for Immediate Delivery:** Cord prolapse typically requires emergency cesarean section. Prepare the patient for surgery and ensure neonatal resuscitation equipment is ready.

- **Documentation:** Record the time of membrane rupture, time of cord prolapse identification, interventions performed, and fetal heart rate response.

Nurses should prioritize cord prolapse over other PROM complications such as infection, as the risk of fetal death from hypoxia is immediate and catastrophic if not promptly relieved.

## 핵심 개념

- **Cord Prolapse** — An obstetric emergency where the umbilical cord descends through the cervix into the vagina after membrane rupture, leading to cord compression and fetal hypoxia.
- **Premature Rupture of Membranes (PROM)** — Spontaneous rupture of the amniotic sac before the onset of labor, increasing the risk of infection and cord prolapse.
- **ABC Framework in Obstetrics** — A priority-setting model adapted for maternal-fetal care, focusing on immediate threats to fetal oxygenation and circulation, such as cord compression.
- **Variable Decelerations** — Abrupt decreases in fetal heart rate caused by umbilical cord compression, often seen with cord prolapse and indicating fetal distress.
- **Wharton's Jelly** — A gelatinous substance within the umbilical cord that protects blood vessels from compression; its absence in velamentous insertion increases vessel vulnerability.

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