A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?

a.Panting helps to control the urge to push and can slow down the delivery, which is important to prevent rapid delivery that could cause injury to both the mother and the baby. It allows the nurse or healthcare provider to better manage the delivery process.

b.Slow-paced breathing is often used during early labor to help manage pain and anxiety. However, when the baby’s head is crowning, panting is more effective in controlling the urge to push and slowing down the delivery process.

c.While deep cleansing breaths can be helpful during contractions to manage pain and focus, they are not as effective as panting in controlling the urge to push during the crowning phase.

d.While it might seem natural to encourage pushing when the baby’s head is crowning, it’s important to control the delivery to prevent rapid birth, which can cause injury to both the mother and the baby. Encouraging the mother to pant helps slow down the process, allowing for a more controlled and safer delivery.

The correct answer is C. Insert a gloved hand into the vagina to relieve pressure on the cord.

A. Covering the cord with a sterile, moist saline dressing is a potential action, but relieving pressure on the cord takes precedence. This can be done by manually elevating the presenting part of the fetus off the cord.

B. Placing the client in a knee-chest position may be recommended after taking the immediate action of relieving pressure on the cord. Elevating the hips may help reduce cord compression.

C. Inserting a gloved hand into the vagina to relieve pressure on the cord is the priority action.

By manually lifting the presenting part off the cord, the nurse can help restore blood flow to the fetus and prevent umbilical cord compression.

D. Preparing the client for an immediate birth may be necessary, but the immediate action to relieve pressure on the cord should be performed first. The healthcare provider will determine the need for urgent delivery based on the clinical situation.