A client who is in labor states, "I think my water just broke?" The nurse notes that the umbilical cord is on the perineum. Which action should the nurse perform first?
Explanation & Rationale
Rationale: A. Notify the operating room team: While notifying the OR team for an emergent cesarean delivery is crucial, immediate maternal positioning to relieve pressure on the prolapsed cord takes priority to prevent fetal hypoxia. B. Administer a fluid bolus of 500 mL: Giving IV fluids can help maintain maternal blood pressure and perfusion, but it does not relieve compression of the prolapsed umbilical cord, which is the most immediate threat to the fetus. C. Place the client in Trendelenburg: Placing the client in Trendelenburg (head down, hips elevated) helps relieve pressure of the presenting fetal part on the prolapsed cord, improving fetal oxygenation. This is the priority emergency action to prevent hypoxia. D. Administer oxygen via face mask: Providing supplemental oxygen increases fetal oxygenation indirectly but does not remove the mechanical compression of the cord. It should be done immediately after maternal positioning.