A nurse rushes to the room to assess a client due to a noted prolonged fetal heart rate deceleration, HR 118 bpm on the monitor. Upon entering, the client reports a feeling of something weird between her legs. Upon assessment, an umbilical cord prolapse is noted. Team members are alerted to the emergency and the nurse's need for assistance. Education is provided to the client at this time explaining the complication and nursing interventions. The client becomes tearful but verbalizes understanding. The nurse reviews the electronic health record and documents care in the nursing progress notes.
Which actions by the nurse are implemented to enhance safety for the laboring client and fetus with a prolapsed cord? Select all that apply.

Choice A rationale

Contractions that are only 20 mm Hg in strength with a baseline resting tone of 5 to 8 mm Hg indicate hypotonic uterine dysfunction. This is characterized by insufficient uterine contraction power, not hypertonic resting tone. Oxytocin is an exogenous hormone that mimics the effects of the naturally released hormone, acting on uterine smooth muscle cells to increase the frequency, duration, and strength (intensity) of the contractions, which should ideally be 50 to 80 mm Hg during active labor.

Choice B rationale

Suggesting relaxation is inappropriate because these contraction patterns are ineffective and unlikely to spontaneously strengthen enough to cause adequate cervical change. Hypotonic contractions typically lead to a protracted labor pattern. The smooth muscle fibers of the uterus require sufficient stimulation to fully activate the contractile proteins actin and myosin. The low intensity and inadequate pressure of these contractions will not result in optimal cervical effacement and dilation.

Choice C rationale

These contractions are hypotonic, not hypertonic. Hypertonic contractions are characterized by high resting tone (above 15 mm Hg) and often painful, ineffective, erratic contractions. A period of rest is generally recommended for hypertonic contractions to reduce uterine irritability and oxygen consumption. However, for hypotonic dysfunction, augmentation (Choice A) is usually required to safely expedite the labor process and reduce risk of infection.

Choice D rationale

While upright positions like sitting or walking can use gravity to help the fetal head apply pressure to the cervix and stimulate endogenous oxytocin release, this response is less effective than recognizing the need for potential pharmacological augmentation. The contractions are described as rarely higher than 20 mm Hg, suggesting a significant need for intervention beyond simple position change to achieve the necessary 50 to 80 mm Hg intensity for progression.

Choice A rationale

Placing a rolled towel under the client's knees offers minimal elevation to the hips and would be insufficient to relieve pressure on the prolapsed umbilical cord. Elevation of the hips is critical to displace the fetus and alleviate cord compression, thereby restoring umbilical blood flow and preventing fetal hypoxia and brain damage. More effective positioning, like Trendelenburg or modified Sims, is required to optimize this decompression and support fetal safety.

Choice B rationale

Immediate notification of the obstetric health care provider is a priority due to the acute, life-threatening nature of an umbilical cord prolapse, which requires rapid definitive intervention. This allows the provider to prepare for an immediate delivery, typically by Cesarean section, which is the fastest way to resolve the compression and prevent fetal mortality from prolonged hypoxia and acidosis.

Choice C rationale

Administering oxygen via a non-rebreather mask (typically 10-15 L/min) to the client increases the maternal partial pressure of oxygen (PO_2), which in turn elevates the oxygen available for placental transfer to the fetus. This maximizes fetal oxygenation and helps mitigate the effects of hypoxia resulting from the compromised umbilical circulation.

Choice D rationale

Positioning the client in a Trendelenburg (supine with the head lower than the feet) or modified Sims (lateral recumbent with the hips elevated) utilizes gravity to displace the fetal presenting part away from the pelvis and the compressed cord. This crucial maneuver aims to relieve pressure on the prolapsed umbilical cord and restore umbilical blood flow, thereby preventing fetal distress.

Choice E rationale

Continuous internal fetal monitoring (IFM) requires the placement of a fetal scalp electrode and an intrauterine pressure catheter (IUPC). While continuous monitoring is essential, IFM is contraindicated in the setting of a prolapsed cord because the instrumentation could potentially worsen the cord compression or introduce infection. External monitoring should be used.

Choice F rationale

Using a sterile gloved hand to exert gentle, sustained upward pressure on the presenting part aims to manually elevate the fetus, thereby relieving compression on the prolapsed umbilical cord. This is a critical and immediate life-saving intervention to restore blood flow to the fetus while preparations are made for emergency delivery to avoid fetal anoxia.

Choice G rationale

Umbilical cord prolapse is an obstetric emergency requiring immediate delivery to prevent severe fetal hypoxia, acidosis, and potentially death. Immediate preparation for a Cesarean birth is the standard, safest, and most rapid definitive intervention to deliver the fetus before prolonged compression causes irreversible harm.