Question

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?

a) Push the umbilical cord back into the vagina.

b) Elevate the client's hips and position her in a knee-chest position.

c) Administer pain medication to the client.

d) Encourage the client to push vigorously.

Answer 1

The nurse should elevate the client's hips and position her in a knee-chest position when observing the umbilical cord protruding during a vaginal examination.

Step-by-step explanation:

When a nurse observes the umbilical cord protruding from the vagina during a vaginal examination, the nurse should take the following action: b) Elevate the client's hips and position her in a knee-chest position.

This position helps relieve pressure and prevent compression of the umbilical cord, which could impair blood flow to the fetus.

Calling for assistance is important, but pushing the umbilical cord back into the vagina or encouraging the client to push vigorously could cause further complications.