Question

The pregnant client is admitted to the emergency room with a prolapsed umbilical cord. Which action is most appropriate? A. Cover the cord with dry, sterile gauze B. Place the client in high Fowler's position C. Push up on the presenting part with an examining finger D. Begin an IV of normal saline at keep-open rate

Short answer

Answer: The most appropriate action in this situation is to push up on the presenting part with an examining finger, as this helps relieve pressure on the umbilical cord and maintain blood flow and oxygen supply to the baby.

Step-by-step solution

Option A: Cover the cord with dry, sterile gauze

Covering the prolapsed umbilical cord with dry, sterile gauze helps to protect the cord from damage and reduces the risk of infection. This is a necessary step, but may not be the most appropriate action in this emergency situation.

Option B: Place the client in high Fowler's position

High Fowler's position involves elevating the head of the client's bed to a 90-degree angle. This position is typically used for clients with respiratory issues, but it is not the optimal position for a pregnant client with a prolapsed umbilical cord. Instead, the client should be placed in a different position, such as Trendelenburg or knee-chest position, to relieve pressure on the cord.

Option C: Push up on the presenting part with an examining finger

Applying upward pressure on the presenting part (baby's head or buttocks) with an examining finger can help to relieve pressure on the umbilical cord, which is important in order to maintain blood flow and oxygen supply to the baby. This action should be taken immediately when a prolapsed umbilical cord is identified, making it a crucial step in this emergency situation.

Option D: Begin an IV of normal saline at keep-open rate

Administering an IV of normal saline at a keep-open rate helps to maintain the client's hydration and electrolyte balance. While this can be a useful intervention during labor and delivery, it is not the most urgent or appropriate action in the case of a prolapsed umbilical cord. Based on the analysis, the most appropriate action: C. Push up on the presenting part with an examining finger is the correct and most appropriate action to take in this emergency situation involving a prolapsed umbilical cord. This action will help to relieve pressure on the cord, ensuring blood flow and oxygen supply to the baby, reducing the risk of complications or harm.