The nurse hears a pregnant client yell, "oh my! the baby is coming! " after placing the client in a supine position and trying to maintain some privacy, the nurse sees that the neonate's head is being born. what should the nurse do first?

In an emergency in which the neonate's head is already delivering, the first action by the nurse should be to check for the presence of a cord around the neonate's neck. If the cord is present, the nurse should gently remove it from around the neck. The mother should be told to breathe gently and avoid forceful bearing-down efforts, which could lead to lacerations. Although blood and bodily fluid precautions are always present in client care, this is an emergency. If possible, the nurse should put on gloves. Suctioning the mouth can be done after the nurse has checked that the cord is not around the neonate's neck. Telling the mother that help is on the way is not reassuring because emergency medical technicians may take some time to arrive. Delivery is imminent because the neonate's head is delivering.

To check for the presence of cord around the neonates neck.

Explanation:

In such a case as given in the question where the neonate's head is already delivering, the first action by the nurse should be to check for the presence of a cord around the neonate's neck.If the nurse finds out that a cord is present around the neonate's neck then she should gently remove it from around the neck. Further, the nurse should tell the mother to breathe gently and avoid any forceful movements and should start preparing for the delivery immediately.