Difficulty: Medium
Average Score: 68%
Simulated
Passage / Scenario
A nurse is caring for a patient who reports spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and notices that the umbilical cord is protruding.After calling for assistance and notifying the provider, which of the following actions should the nurse take next?
Correct answer
C
Rationale
The correct answer is C because performing a vaginal examination by applying upward pressure on the presenting part helps assess the progress of labor and fetal descent, which is crucial in determining the need for immediate intervention or transfer. Initiating an infusion of IV fluids (A) is not the next step as the priority is to assess the progress of labor first. Administering oxygen (B) may be important but not the immediate next step after notifying the provider. Performing a vaginal examination (C) is more critical in this situation. Covering the umbilical cord with a sterile saline towel (D) is not necessary at this point.