Maternal / Newborn Question #14

Question

The nurse working in labor and delivery noticed the umbilical cord protruding through the cervix. What priority actions will the nurse perform? Select all that apply.

Answers

  1. Administer oxygen 3L/min by nasal cannula.
    • Rationale:
  2. Use sterile-saline saline-soaked towel to the visible cord.
    • Rationale:
  3. Insert gloved hand on either side of cord to relieve pressure from fetal presenting part.
    • Rationale:
  4. Contact team for possible cesarean birth.
    • Rationale:

Overview

Explanation

The nurse should employ all the measures except option A, including calling for assistance immediately, ensuring IV access and beginning infusion of fluids. The nurse will also provide continuous fetal heart monitoring for variable decelerations, and monitoring for fetal asphyxia and signs of fetal hypoxia. While oxygen will be administered, it should be 8-10 L/min by nasal cannula since oxygen delivery is compromised in the fetus.

Learning Outcomes

Test Taking Tip

Video Rationale