Difficulty: Medium
Average Score: 77%
Simulated
Passage / Scenario
A nurse is caring for a client 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
D
Rationale
The correct answer is D: Perform a vaginal examination by applying upward pressure on the presenting part. This action is crucial to assess the progress of labor and determine if there is a risk of cord prolapse, a serious obstetric emergency. By applying upward pressure, the nurse can alleviate pressure on the cord and prevent potential complications. Administering oxygen (A) may be necessary but is not the immediate priority. Covering the umbilical cord (B) does not address the potential emergency. Initiating IV fluids (C) is important, but assessing the cord position takes precedence.