# A nurse is caring for a laboring client when the umbilical cord suddenly prolapses through the cervix. What is the most critical immediate nursing intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543030 > language: ko > subject: Maternal Newborn Health ## 문제 A nurse is caring for a laboring client when the umbilical cord suddenly prolapses through the cervix. What is the most critical immediate nursing intervention? Emergency management of prolapsed umbilical cord during labor ## 보기 1. Place the client in Trendelenburg position and prepare for immediate cesarean delivery 2. Apply sterile saline-soaked gauze to the exposed cord and monitor fetal heart rate continuously 3. Insert a gloved hand into the vagina to elevate the presenting part off the compressed cord **✔ 정답** 4. Administer high-flow oxygen via face mask and establish large-bore IV access **정답: 3** ## 해설 The most critical immediate intervention is manually elevating the presenting part off the compressed cord with a gloved hand to relieve pressure and restore fetal circulation. Other options are supportive but do not directly address the life-threatening mechanical compression. ## 심화 해설 Understanding Umbilical Cord Prolapse Umbilical cord prolapse (UCP) is a rare but critical obstetric emergency where the umbilical cord descends through the cervix ahead of or alongside the fetal presenting part. The primary danger is compression of the cord between the presenting part and the maternal pelvis, which rapidly compromises fetal oxygenation. The reported incidence is approximately 1 to 6 per 1000 pregnancies [1]. When this occurs, the nurse's immediate actions must focus on relieving that compression to restore fetal circulation while preparations for definitive delivery are made. Analysis of the Correct Answer The most critical, immediate nursing intervention is to insert a gloved hand into the vagina to elevate the presenting part off the compressed cord. This action directly addresses the pathophysiology of the emergency. By manually lifting the fetal head or breech, the nurse creates physical space within the pelvis, immediately decompressing the umbilical cord. This restores blood flow and oxygen delivery to the fetus, buying crucial time. This intervention is the highest priority because it provides a direct, mechanical solution to the cord compression that is causing fetal hypoxia. The case report highlights that UCP is an emergency that "threatens fetal oxygenation," making the immediate relief of that threat the absolute priority [1]. Why the Other Options Are Not the Most Critical First Step While the other listed interventions are important components of the overall emergency response, they are secondary to physically relieving cord compression: - **Option 1:** Placing the client in Trendelenburg position or a knee-chest position uses gravity to try and shift the presenting part away from the cord. However, this is a passive maneuver and may not be sufficient to relieve the compression. Manual elevation is a more direct and reliable method and should be performed first. - **Option 2:** Applying sterile saline-soaked gauze to the exposed cord is done to prevent drying and vasospasm of the umbilical vessels. Monitoring fetal heart rate is essential for assessing the fetus. These are important but are not the priority action that saves the fetus's life in the first moments; they should be performed concurrently or immediately after the presenting part is elevated. - **Option 4:** Administering high-flow oxygen and establishing IV access are supportive measures to improve maternal oxygenation and prepare for potential surgery. They do not, however, address the mechanical obstruction that is the direct cause of the emergency. The definitive treatment for UCP, as noted in the literature, is often an emergency cesarean delivery, but the immediate nursing action to prevent fetal demise is manual elevation of the presenting part [1]. Clinical Priority and Rationale The clinical reasoning follows the ABC (Airway, Breathing, Circulation) framework adapted for fetal well-being. The cord compression represents a direct obstruction to fetal circulation. The nurse's gloved hand becomes a critical intervention to restore that circulation. This is a situation where a nursing action directly and immediately alters the pathophysiological process. The case report underscores that UCP is a dynamic and life-threatening event where rapid, decisive action is paramount to improving neonatal outcomes [1]. The nurse must maintain this manual elevation continuously until the surgeon takes over in the operating room for a cesarean delivery, ensuring the cord remains decompressed throughout the transfer and preparation process. References (research sources) - [1]A rare case report of umbilical cord prolapse in a second-trimester twin pregnancy: Diagnostic, management, and prognostic challenges.Case reportFathallah I, Al-Talep A, Alajrd AA, Al-Ali M. (2025) · DOI: 10.1016/j.ijscr.2025.111578 ## 임상 시나리오 Clinical Practice Guide: Umbilical Cord Prolapse Immediate Management to Prevent Fetal Hypoxia Immediate Priority Action The nurse must immediately insert a sterile gloved hand into the vagina and elevate the presenting part off the compressed cord. This manual elevation is the only intervention that directly relieves the mechanical obstruction and restores fetal circulation. The hand should remain in place, continuously maintaining elevation, until the surgical team relieves you in the operating room. Simultaneous Adjunct Interventions - Position the client in Trendelenburg or knee-chest position to use gravity to reduce pressure on the cord. - Administer high-flow oxygen via face mask to maximize maternal-fetal oxygenation. - Apply sterile saline-soaked gauze to any exposed cord to prevent drying and vasospasm; minimize handling to avoid vasospasm. - Establish large-bore IV access for fluid resuscitation and preoperative preparation. - Continuously monitor fetal heart rate to assess for resolution of bradycardia. Critical Safety Points - Never attempt to replace the cord into the uterus; this increases trauma and spasm risk. - Do not remove your hand once elevation is established until the surgeon is ready for immediate cesarean delivery. - If the cervix is fully dilated and delivery is imminent, preparation for assisted vaginal delivery may proceed, but manual elevation continues until the presenting part descends past the cord. - Document the time of prolapse discovery, initial fetal heart rate, and time of manual elevation initiation. ## 핵심 개념 - **Umbilical Cord Prolapse** — An obstetric emergency where the umbilical cord descends through the cervix ahead of or alongside the fetal presenting part, risking compression and fetal hypoxia. - **Presenting Part** — The portion of the fetus (e.g., head or breech) that is closest to the internal os of the cervix and leads the way through the birth canal. - **Cord Compression** — Pressure on the umbilical cord that reduces or stops blood flow and oxygen delivery from the placenta to the fetus. ## 같은 주제 문제 - [A nurse is caring for a laboring client when the membranes rupture spontaneously. 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