hard · NCLEX-RN health-promotion
A nurse is caring for a client, Jordan, at 40 weeks gestation in active labor. After spontaneous rupture of membranes, the fetal heart rate (FHR) monitor shows a sudden, abrupt drop to 70/min with a V-shaped geometry. Upon vaginal examination, the nurse palpates a pulsating loop of tissue. Which actions belong in the immediate plan? Select all that apply.
- Perform a forceful attempt to replace the cord into the uterine cavity
- Position the client in a knee-chest or Trendelenburg position
- Apply upward digital pressure against the fetal presenting part
- Cover the protruding cord with sterile gauze soaked in room-temperature water
- Increase the oxytocin infusion to expedite vaginal delivery
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