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A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take next?

a) Elevate the client's hips
b) Insert a urinary catheter
c) Push the cord back into the uterus
d) Administer oxytocin to speed up labor

1 Answer

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Final answer:

In case of an umbilical cord prolapse, the nurse should elevate the client's hips to relieve pressure on the cord and prevent fetal asphyxia, without attempting any other procedures that could worsen the situation like administering oxytocin.

Step-by-step explanation:

If a nurse observes the umbilical cord protruding from the vagina during labor, the correct action to take after calling for assistance is a) Elevate the client's hips. This is a critical emergency known as umbilical cord prolapse and immediate action is necessary to relieve pressure on the cord to prevent asphyxia of the fetus. Elevating the client's hips can help reduce compression on the cord.

The nurse should not attempt to insert a urinary catheter, push the cord back into the uterus, or administer oxytocin to speed up labor. The use of oxytocin may intensify uterine contractions, increasing pressure on the prolapsed cord and potentially worsening fetal distress. Quick and appropriate actions are vital for the safety of both the mother and the child.

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