1. ♦ 3. Assessment:
   1. Visualization of cord outside (or inside) vagina.
   2. Palpation of pulsating mass on vaginal examination.
   3. Fetal distress—variable deceleration and persistent bradycardia.
2. ♦ 4. Analysis/nursing diagnosis:
   1. Impaired gas exchange, fetal, related to interruption of blood flow from placenta/ fetus.
   2. Anxiety/fear, maternal, related to knowledge of fetal jeopardy.
3. ♦ 5. Nursing care plan/implementation:
   1. Goal: reduce pressure on cord.
      1. E (1) Position: knee to chest; lateral modified Sims’ with hips elevated; modified Trendelenburg.
      2. With gloved hand, support fetal presenting part.
   2. ► b. Goal: increase maternal/fetal oxygenation: oxygen per mask (8-10 L/min).
   3. ► c. Goal: protect exposed cord: continuous pressure on the presenting part to keep pressure off cord.
   4. Goal: identify fetal response to above measures, reduce threat to fetal survival: monitor FHR continuously.
   5. Goal: expedite termination of threat to fetus: prepare for immediate cesarean birth.
   6. Goal: support mother and significant other by staying with them and explaining.
4. ♦ 6. Evaluation/outcome criteria:
   1. FHR returns to normal rate and pattern.
   2. Uncomplicated birth of viable infant.
7. Summary of danger signs during labor
   1. Contractions—strong, every 2 min or less, lasting 90 sec or more; poor relaxation between contractions.
   2. Sudden sharp abdominal pain followed by boardlike abdomen and shock—abruptio placentae or uterine rupture.
   3. Marked vaginal bleeding.
   4. FHR periodic pattern decelerations—late; variable; absent (see Figure 4-10).
   5. Baseline.
      1. Bradycardia (<100 beats/min).
      2. Tachycardia (>160 beats/min).
   6. Amniotic fluid.
      1. Amount: excessive; diminished
      2. Odor.
      3. Color: meconium stained; port-wine; yellow.
      4. 24 hr or more since rupture of membranes.
   7. Maternal hypotension, or hypertension.