DIAGNOSIS GOAL INTERVENTION RATIONALE EVALUATION

risk for fetal injury After 8 hours of •Perform To determine the Goal met after 8
related to nursing vaginal cervical length, hours of nursing
prolapsed cord into intervention, the examination. effacement, intervention,
the presenting part, fetal heart rate will dilatation, and
pressure is
related to impaired return to normal. station of
gas exchange the presenting removed from the
(fetal) related to part presenting part of
interruption of the
blood flow from •Monitor FHR -Baseline umbilical cord,
the placenta to the by obtaining status of FHR FHR returns to a
fetus as evidenced an initial 20 should be normal rate, and
by FHTs are not minute 110-160
the baby is
audible with a electronic beats/minute,
hand held Doppler fetal with baseline delivered
monitoring variability of immediately.
tracing 6-10 beats/minute
s. Accelerations
of 15 beats/minute
X 15 seconds
are a reassuring
sign of fetal
well-being.

•Assist -To cause the

patient into a fetal head to
chest-knee fall back from
position to the cord
elevate the which
buttock prevents
(trendelenbur further cord
g) compression
until delivery
can take
place.

•Elevate the -This will

presenting relieve
part and pressure on
separate the the cord.
cord from the
presenting part and
pelvis by use of
gloved fingers
inserted into the
vagina to the
cervix.

•Administer -helpful to
oxygen at 10 improve
L/min by face oxygenation
mask to the to the fetus.
woman.

•Administer -to reduce

prescribed uterine
tocolytic activity and
agent (e.g. pressure on
terbutaline) the fetus.

•Prepare for -This is an

vaginal birth if obstetrical
cervix is fully emergency
dilated or because the
prepare for cord is at
immediate high risk for
C/S compression,
blocking
oxygen and
blood flow to
the baby
thus, the
baby needs
to be
delivered
immediately.