Questions: 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? Cover the cord with a sterile, moist saline dressing. Prepare the client for an immediate birth. Place the client in knee-chest position. Insert a gloved hand into the vagina to relieve pressure on the cord.

The answer is the third one: Place the client in knee-chest position.

Explanation for each option:

1. Cover the cord with a sterile, moist saline dressing.

   • This action is important to prevent the cord from drying out and to reduce the risk of infection. However, it is not the immediate priority when the umbilical cord is prolapsed.

2. Prepare the client for an immediate birth.

   • While an immediate birth may be necessary, the first priority is to relieve pressure on the umbilical cord to prevent fetal hypoxia.

3. Place the client in knee-chest position.

   • This is the correct first action. Placing the client in the knee-chest position helps to relieve pressure on the umbilical cord by using gravity to shift the fetus away from the pelvis, which can help maintain blood flow through the cord.

4. Insert a gloved hand into the vagina to relieve pressure on the cord.

   • This action can be necessary to manually relieve pressure on the cord, but it should be done after positioning the client to help alleviate pressure naturally.

In summary, the immediate priority in the case of a prolapsed umbilical cord is to relieve pressure on the cord to ensure adequate blood flow to the fetus. Placing the client in the knee-chest position is the most effective initial action to achieve this.