vSim Maternity | Carla Hernandez (Prolapsed Cord)
The nurse is preparing for an emergency cesarean birth for a patient who has prolapsed cord visible at the vulva. Which interventions would the nurse take for this surgical procedure?
Obtain an informed consent from the patient or family member Review results for diagnostic tests, including CBC, ABO group, Rh compatibility, Urinalysis Administer the ordered preoperative intravenous medications Assess the intravenous site for patency and hang a full bag of IV fluids
A laboring woman called the nurse to report her bag of water broke and she feels a pulsation in her vagina. The nurse notes variable decelerations with fetal bradycardia on the fetal monitor and suspects prolapsed umbilical cord. Put into order he interventions the nurse should perform
1) call the charge nurse to notify the provider and prepare for immediate delivery 2) Insert a gloved hand into the vagina to relieve pressure on the umbilical cord 3) assist the patient into the knee-chest position 4) Administered oxygen by nonrebreather mask at 10 L/min 5) Explain emergency measures and rationales to the patient and her support person 6) Ensure that there are further abnormal fetal heart rate patterns 7) Document the actions and procedures taken to resolve this situation
A woman in active labor reports to the nurse that she thinks that her bag of waters has broken. What is the first assessment that the nurse performs at this time?
Monitor the fetal heart rate and pattern Explanation: When the fetal membranes rupture, then the presenting part can put pressure on the umbilical cord. the first assessment to make is the fetal heart rate and pattern to ensure the fetus is getting enough oxygen through the umbilical cord
The nurse takes measures to preserve the integrity of the visible umbilical cord prolapse to maintain blood flow to the fetus. Which of the following are appropriate measures?
Assess the exposed umbilical cord for color and pulsation Use a gloved hand to lift the presenting part of the cord Explanation: The nurse would try to reestablish blood flow to the fetus by placing a gloved hand into the vagina and lifting the presenting part off the cord. the exposed umbilical cord is not pushed back into the vagina, because this action could cause the umbilical vessels to be kinked and cut off the blood flow to the fetus
The nurse is admitting a laboring woman at 39 weeks gestation. Which of the following are risk factors for prolapsed umbilical cord?
Estimated fetal weight of 2,400 g (5 lb, 1 oz) Amniotomy performed at station -2 Multiple gestation Amniotic fluid 2,200 mL Explanation: risk factors for an umbilical cord prolapse include the following" Low birth weight, being second twins, transverse lie, breech presentation, preterm labor (less than 37 weeks), Poly hydramnios (greater than 2,000 mL), amniotomy (especially when fetus is not engaged), premature rupture of the membranes, placenta previa, and a long cord
During the initial assessment for Carla Hernandez, there was bradycardia, late decelerations, and minimal variability. The nurse could determine that measures to relieve umbilical cord compression were successful by which of the following evaluative findings?
Long-term variability was 10 to 15 beats per minute The umbilical cord had a pulse The umbilical cord had a pH of 7.3 and maternal oxygen saturation was at 98%