A laboring client at -2 station has a spontaneous rupture of the membranes, and a cord immediately protrudes from the vagina. The nurse should first:

A laboring client at -2 station has a spontaneous rupture of the membranes, and a cord immediately protrudes from the vagina. The nurse should first:

• A. Call for assistance from the medical team.
• B. Place gentle pressure upward on the fetal head.
• C. Administer IV fluids and wait for delivery.
• D. Apply a heat lamp to the perineal area.

Answer: (B)

Relieve cord compression immediately. When a prolapsed umbilical cord occurs, the urgent issue is ongoing cord compression which can rapidly compromise fetal oxygenation. The first action is to insert a gloved hand into the vagina and gently elevate the presenting part (the fetal head) off the cord to relieve this pressure. This helps maintain blood flow to the fetus while the team coordinates delivery. After doing this, position the mother to further reduce compression (for example, knee-chest or Trendelenburg), keep the cord moist with sterile gauze, administer oxygen to the mother if available, and call for help to expedite delivery. Other actions like waiting for delivery or applying heat do not address the immediate problem of cord compression.

Relieve cord compression immediately. When a prolapsed umbilical cord occurs, the urgent issue is ongoing cord compression which can rapidly compromise fetal oxygenation. The first action is to insert a gloved hand into the vagina and gently elevate the presenting part (the fetal head) off the cord to relieve this pressure. This helps maintain blood flow to the fetus while the team coordinates delivery. After doing this, position the mother to further reduce compression (for example, knee-chest or Trendelenburg), keep the cord moist with sterile gauze, administer oxygen to the mother if available, and call for help to expedite delivery. Other actions like waiting for delivery or applying heat do not address the immediate problem of cord compression.