Today’s NCLEX question targets early recognition of a high-risk obstetric emergency and the nurse’s first priority action. This matters because labor and delivery can change fast. A subtle finding can become a life-threatening event for both the pregnant patient and the fetus within minutes. Strong prioritization helps the nurse protect oxygenation, circulation, and safety without delay.
Clinical Scenario
A 29-year-old client at 39 weeks of gestation is admitted to the labor unit in active labor. She is gravida 2, para 1, and has had an uncomplicated pregnancy except for mild gestational hypertension controlled with rest and monitoring. Her membranes rupture spontaneously during a cervical exam. The fluid is clear. Immediately after rupture, the fetal heart rate on the monitor drops from a baseline of 140/min to 78/min and stays there. The client reports feeling pressure, and on quick assessment the nurse notes a loop of umbilical cord visible at the vaginal opening.
The Question
Which action should the nurse take first?
Answer Choices
- A. Apply oxygen at 10 L/min by nonrebreather mask and continue to observe the fetal tracing
- B. Place the client in high-Fowler position and prepare for internal fetal monitoring
- C. Using a sterile gloved hand, lift the presenting part off the cord and call for immediate assistance
- D. Start an IV fluid bolus and recheck the fetal heart rate in 5 minutes
Correct Answer
C. Using a sterile gloved hand, lift the presenting part off the cord and call for immediate assistance
Detailed Rationale
This client has a prolapsed umbilical cord. The cord is visible, and the fetal heart rate suddenly dropped after membrane rupture. That pattern is an emergency because the presenting fetal part can compress the cord and sharply reduce blood flow and oxygen to the fetus.
The nurse’s first priority is to relieve pressure on the cord right away. The fastest way to do that is to insert a sterile gloved hand and elevate the presenting part off the cord. This is not comfortable or routine, but it is the action most likely to improve fetal oxygen delivery in that moment. At the same time, the nurse should call for help because this client will likely need an urgent operative birth if the heart rate does not recover quickly.
After that first action, the nurse should continue emergency measures that support fetal oxygenation and reduce compression. These include repositioning the client, often into knee-chest or Trendelenburg, to use gravity to shift the fetus off the cord. Oxygen can be applied as an added support measure. The nurse should also stop any oxytocin infusion if one is running, because stronger contractions can worsen cord compression. Continuous fetal monitoring is needed to see whether the fetal heart rate improves.
The nurse should avoid handling the cord more than necessary. Excess manipulation can cause vasospasm, which further reduces fetal blood flow. If the cord is protruding, it should be kept moist with sterile saline-soaked gauze as directed by facility protocol while the team prepares for birth.
The nurse should also monitor the client’s status while moving quickly. That includes maternal vital signs, contraction pattern, fetal heart rate response, and readiness for emergency delivery. Clear communication matters here. The nurse should report what happened, when it happened, the fetal heart rate pattern, and the interventions already started.
The reason this answer is correct comes down to priorities. In NCLEX questions, when a visible prolapsed cord and persistent fetal bradycardia are present, the first action is the one that immediately relieves mechanical compression of the cord. Other supportive steps matter, but they come after pressure is removed.
Why the Other Options Are Wrong
A. Apply oxygen at 10 L/min by nonrebreather mask and continue to observe the fetal tracing
Oxygen may help support fetal oxygenation, but it does not fix the main problem: direct cord compression. Waiting and watching while the cord remains compressed delays the life-saving action. Observation is not enough in a true prolapsed cord emergency.
B. Place the client in high-Fowler position and prepare for internal fetal monitoring
High-Fowler position is the wrong direction for this problem. Upright positioning can increase downward pressure of the presenting part onto the cord. Internal fetal monitoring also delays urgent care and is not the first priority. The issue is not better data collection. The issue is restoring blood flow to the fetus.
D. Start an IV fluid bolus and recheck the fetal heart rate in 5 minutes
An IV bolus can be useful in some cases of fetal intolerance of labor, especially if maternal hypotension is suspected. But here, the cause is obvious and mechanical. Waiting 5 minutes with a compressed cord is unsafe. The nurse must act immediately to reduce compression before considering secondary supportive measures.
Key Takeaways
- A sudden prolonged fetal heart rate drop right after membrane rupture should make you think about cord prolapse, especially if the cord is felt or seen.
- The first priority is to manually lift the presenting part off the cord with a sterile gloved hand.
- Call for help immediately. This is an obstetric emergency.
- Reposition to reduce cord pressure, such as knee-chest or Trendelenburg, based on unit protocol and patient condition.
- Stop oxytocin if infusing and continue continuous fetal monitoring.
- Avoid unnecessary handling of the cord because it can cause vasospasm.
- On-shift mini-checklist: recognize the sudden bradycardia, assess for cord prolapse, relieve pressure manually, call the team, reposition the client, stop uterotonics, apply supportive oxygen if ordered or per protocol, and prepare for urgent birth.
Quick Practice Extension
1. A laboring client has recurrent variable decelerations after amniotomy, but no visible cord is present. What focused assessments and interventions should the nurse perform first?
2. During an emergency cesarean birth for prolapsed cord, what key information should the nurse communicate during handoff to the surgical team?
Category for today: OB
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