A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?

Explanation

Choice A Reason:

Covering the exposed umbilical cord with a sterile saline-saturated towel is an appropriate intervention to prevent the cord from drying out and to reduce the risk of infection. However, this is not the most immediate action that should be taken. The priority is to relieve pressure on the umbilical cord to restore blood flow to the fetus, which is more urgent than covering the cord.

Choice B Reason:

Administering oxygen can help improve maternal oxygenation, which in turn can benefit the fetus. However, in this situation, the immediate priority is to relieve the pressure on the umbilical cord to prevent fetal hypoxia. Administering oxygen is important but secondary to the mechanical relief of cord compression.

Choice C Reason:

This is the most critical and immediate action. Applying upward pressure on the presenting part (e.g., the fetal head) can relieve pressure on the umbilical cord, which is crucial to restore blood flow to the fetus and prevent fetal hypoxia and bradycardia. This action directly addresses the life-threatening situation posed by a prolapsed umbilical cord.

Choice D Reason:

Initiating IV fluids can help maintain maternal blood pressure and support fetal circulation. However, this intervention is not as immediate or directly life-saving as relieving the pressure on the umbilical cord. It can be done after the more urgent interventions are initiated.

Explanation

Choice A Reason:

Moving the client onto their hands and knees is incorrect. Moving the client onto their hands and knees is known as the Gaskin maneuver, which is another technique used to alleviate shoulder dystocia during childbirth. However, the McRoberts maneuver specifically involves flexing the client's legs against their abdomen while lying on their back, not changing their position to hands and knees.

Choice B Reason:

Applying pressure to the client's fundus is incorrect. Applying pressure to the client's fundus (the top of the uterus) is not part of the McRoberts maneuver. This action does not directly address the issue of shoulder dystocia and may not effectively resolve the situation.

Choice C Reason:

Pressing firmly on the client's suprapubic area is incorrect. Pressing firmly on the client's suprapubic area (just above the pubic bone) is another technique used to alleviate shoulder dystocia, known as the Rubin maneuver. However, it is not part of the McRoberts maneuver, which focuses on flexing the client's legs against their abdomen to release the impacted shoulder.

Choice D Reason:

Assisting the client in pulling their knees toward their abdomen is correct. The McRoberts maneuver is a technique used to relieve shoulder dystocia during childbirth. It involves flexing the mother's legs tightly against her abdomen, which helps to straighten the pelvis and increase the space available for the baby to be delivered. This maneuver is typically performed by assisting the client in pulling their knees toward their abdomen while lying on their back.