Which of the following would be the initial nursing action if a nurse in the labor room is performing a vaginal assessment on a pregnant client in labor? The nurse notes the presence of the umbilical cord protruding from the vagina.
When cord prolapse occurs. prompt actions are taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. Oxygen at 8 to 10 L/min by face mask is delivered to the mother to increase fetal oxygenation.Options B and D: The nurse should push the call light to summon help. and other staff members should call the physician and notify the delivery room.Option C: No attempt should be made to replace the cord. The examiner. however. may place a gloved hand into the vagina and hold the presenting part off of the umbilical cord.