A nurse is caring for a client in active labor when the fetal heart monitor indicates a sudden deceleration.

Upon assessment, the nurse notes that the umbilical cord is protruding from the vaginal opening.

The nurse immediately calls for assistance and uses a sterile gloved hand to lift the presenting part off of the cord.

The nurse positions the client in a knee to chest position to relieve pressure on the cord.

Fetal heart tones are monitored continuously.

The provider is notified while preparations for an emergency cesarean birth are initiated.

The nurse documents the time of cord prolapse, interventions, and the client response.

Select the portions of the text that indicate priority nursing actions in response to a prolapsed umbilical cord.

Choice A rationale

This action is critical because immediate manual elevation of the fetal presenting part off the prolapsed umbilical cord directly alleviates cord compression, which is the primary cause of fetal hypoxia and acidosis. Sustained compression compromises umbilical blood flow, depriving the fetus of oxygen and nutrients, leading to severe bradycardia and potential neurological damage. This direct intervention aims to restore uteroplacental perfusion.

Choice B rationale

The knee-to-chest position, along with Trendelenburg or modified Sims, leverages gravity to displace the presenting fetal part away from the pelvis and the prolapsed cord. This physical repositioning reduces the pressure exerted by the fetus on the cord, thereby minimizing further compromise of blood flow and maintaining fetal oxygenation. These positions help to prevent further compression.

Choice C rationale

Continuous fetal heart tone monitoring is essential for ongoing assessment of fetal well-being, but it is not a *priority action* in the sense of directly intervening to relieve cord compression. While crucial for evaluating the effectiveness of interventions and guiding subsequent management, the immediate physical actions to relieve pressure take precedence to mitigate acute fetal distress. Normal fetal heart rate is 110-160 beats per minute.

Choice D rationale

Prompt notification of the provider and initiation of preparations for an emergency cesarean birth are paramount because a prolapsed cord often necessitates immediate delivery to prevent prolonged fetal compromise. This action mobilizes the medical team and resources required for rapid surgical intervention, which is the definitive treatment to resolve the life-threatening situation for the fetus.