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.

Step 1 is to convert the oxytocin concentration from units to milliunits (mU):. 20 units× 1000 mU/unit = 20000 mU.

Step 2 is to determine the concentration in mU/mL:. 20000 mU÷ 1000 mL = 20 mU/mL.

Step 3 is to calculate the infusion rate in mL/min:. 4 mU/min÷ (20 mU/mL) = 0.2 mL/min.

Step 4 is to convert the infusion rate from mL/min to mL/hr:. 0.2 mL/min× 60 min/hr = 12 mL/hr. The final calculated answer is 12 mL/hr.

Choice A rationale

Placing a rolled towel under the client's knees might slightly tilt the pelvis but is insufficient to effectively relieve the pressure of the presenting fetal part on the prolapsed umbilical cord. The primary goal in a cord prolapse is to prevent umbilical artery compression, which quickly leads to fetal hypoxia and bradycardia due to compromised blood flow, and a rolled towel under the knees doesn't achieve the necessary change in maternal position to shift the fetus off the cord.

Choice B rationale

While immediately notifying the obstetric health care provider (HCP) is a critical step in managing cord prolapse, it is not the absolute priority over direct physical intervention to protect the fetus. The scientific rationale for prioritizing pressure relief is the immediate threat of profound fetal hypoxemia and acidemia from cord compression, which can cause irreversible brain damage or death within minutes, necessitating an immediate hands-on maneuver.

Choice C rationale

Administering high-flow oxygen via a non-rebreather mask (10-12 L/min) is a standard intervention for fetal distress, aiming to increase the maternal partial pressure of oxygen (P_O_2) and subsequently enhance oxygen transfer across the placenta to the fetus. However, its effectiveness is secondary to relieving the direct mechanical compression of the umbilical cord, which is the immediate cause of the deceleration and hypoxia.

Choice D rationale

Positioning the client into a position like Trendelenburg (head down, feet up) or knee-chest (hands and knees, chest on the bed) uses gravity to displace the fetus upward and away from the cervix, thereby relieving the pressure on the prolapsed umbilical cord. This action immediately restores umbilical blood flow, which is the critical first step to reversing fetal bradycardia and hypoxia caused by cord compression.

Choice E rationale

Preparing the client for an immediate delivery, often via emergency Cesarean section (C-section), is the ultimate treatment for a non-reassuring fetal status secondary to cord prolapse, but it requires preparatory steps and time. Positioning for pressure relief (Choice D) and manual elevation of the presenting part (if necessary) are the immediate, life-saving measures performed before or concurrent with preparation for rapid delivery.

Choice F rationale

Encouraging the client to push with the next contraction would be contraindicated and detrimental. The action of pushing would increase intra-abdominal pressure and directly force the presenting fetal part down onto the prolapsed cord, leading to maximal compression of the umbilical artery and vein. This would cause severe, sustained fetal bradycardia and hypoxemia, dramatically increasing the risk of fetal demise or severe injury.

Choice G rationale

Applying sterile gauze soaked in normal saline to the exposed cord helps to prevent drying of the Wharton's jelly and umbilical vessels, which minimizes vasospasm and maintains blood flow until delivery. Although important for cord preservation, this intervention is secondary to the immediate mechanical relief of compression (Choice D), which addresses the acute life-threatening fetal compromise from lack of blood flow.