Difficulty: Medium
Average Score: 82%
Simulated
Passage / Scenario
A client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vaginaA nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?
Correct answer
A
Rationale
The correct action is choice A: Insert a gloved hand into the vagina to relieve pressure on the cord. This is the priority because it helps prevent umbilical cord compression, which can lead to decreased blood flow to the baby and potential harm. By inserting a gloved hand, the nurse can gently push the presenting part of the baby off the cord, relieving pressure. Covering the cord (choice B) or placing the client in knee-chest position (choice D) does not directly address the immediate need to relieve pressure on the cord. While preparing for an immediate birth (choice C) may be necessary, it is essential to first address the urgent issue of cord prolapse.