QUESTION: "While a 31-year-old multigravida at 39 weeks' gestation in active labor is being admitted, her amniotic membranes rupture spontaneously. The client's cervix is 5 cm dilated and the presenting part is at 0 station. Which of the following should the nurse do first?"
CHOICES
( X ) a.) Perform a vaginal examination to determine dilation.
( X ) b.) Auscultate the client's blood pressure.
( O ) c.) Note the color, amount, and odor of the amniotic fluid.
( X ) d.) Prepare the client for imminent delivery.
RATIONALE: The nurse's first action when membranes rupture spontaneously is to check the odor, consistency, and volume of the amniotic fluid. Because the fetal head is engaged and at 0 station, there is little likelihood of cord prolapse. However, when the fetal head is not engaged, checking for cord prolapse would be the priority when the membranes rupture spontaneously. After rupture of the membranes, vaginal examinations should be kept to a minimum to decrease the chance of infection. Although auscultating the client's blood pressure is important, it is not the priority following spontaneous rupture of membranes. Delivery is not imminent if the client is 5 cm dilated. However, multigravid clients may progress quickly in labor, especially after rupture of the membranes. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
