I. The priority nursing problem in this case is the infant’s safety. When the nurse feels that the umbilical cord is pulsating in the vagina, this means that umbilical cord prolapse has occurred. This means that the perfusion in the umbilical cord is reduced due to compression of the cord by the baby’s presenting part. Hence, nursing interventions are geared toward relieving compression of the cord (Griese & Prickett, 2006). It is important to note that the umbilical cord is still pulsating which means that the baby is still alive inside.
The first nursing intervention is to support the prolapsed umbilical cord by holding or supporting the presenting part by holding that part with a sterile gloved hand to relieve its weight off the umbilical cord. This will lessen the compromise on the placental perfusion. The client’s position can also be changed into a knee-chest position because this position reduces the compression on the umbilical cord. It is also important to teach the client regarding the correct position so that she may cooperate.
The situation should also be explained to the client in order to reduce anxiety which can cause further physiological changes (increasing blood pressure, etc) that will further compromise the placental perfusion. Furthermore, if there is no full cervical dilatation yet, the mother should be prepared for a ceasarian delivery (Ricci ; Kyle, 2009). II. Education on breastfeeding is very important for lactating mothers. They should be taught about the proper techniques, importance, and benefits of breastfeeding to promote this behavior. The outline content of the breastfeeding education is included in the table below.