A client who is pregnant at 39 weeks gestation spontaneously ruptured her membranes while ambulating to the bathroom. After the client returns to bed, which of the following should be the nurse's initial action?
A client who is pregnant at 39 weeks gestation spontaneously ruptured her membranes while ambulating to the bathroom. After the client returns to bed, which of the following should be the nurse's initial action?
A. Assess the color of the amniotic fluid
[29%]
B. Perform a vaginal examination to assess the cervix for dilation
[14%]
C. Inform the client she is now on strict bed rest until further notice
[2%]
D. Assess the fetal heart tones
[54%]
Statistics
Subject/Lesson
Subject
Maternal & Newborn Health
Lesson
Labor/Delivery
Client Need
Test Plan
Health Promotion and Maintenance
Related Topic
Ante/Intra/Postpartum and Newborn Care
Item Type
Item Type
Analysis
Explanation
Choice D is correct. The initial action the nurse should take is to assess the fetal status following the spontaneous rupture of the client's membranes. Although numerous methods may be utilized to evaluate fetal status, assessing fetal heart tones provides reliable information in a relatively prompt manner. Following the assessment of fetal heart tones, the nurse should then assess the color and quality of the amniotic fluid.
Choice A is incorrect. Following a spontaneous rupture of the client's membranes, the priority is for the nurse to assess the fetal status via fetal heart tones. Assessment of the color of the amniotic fluid does not indicate the fetus's current status.
Choice B is incorrect. While certain circumstances may justify performing a vaginal examination to assess for cervical dilatation, nothing in this scenario suggests such intervention. As such, in this scenario, the nurse's priority following a spontaneous rupture of the client's membranes remains to assess the fetal status via fetal heart tones.
Choice C is incorrect. Fetal head engagement and descent are not dependent on the client's movement during labor. Keeping the client on bed rest is not necessary. Often, the client will be encouraged to ambulate.
Learning Objective
Following the spontaneous rupture of a 39-week gestation pregnant client's membranes, prioritize assessing the fetal status via assessment of the fetal heart tones.
Related Videos
4 Key Topics
Amniotic Sac Rupture
30.1 Labor Concepts & Delivery Types
Nursing Process (ADPIE)
15.6 Prioritization Part 2
Additional Info
- To confirm the rupture of a client's membranes, the pH of the fluid may be tested.
- Vaginal fluid may be tested with Nitrazine paper, which turns deep blue at a pH >6.5 (pH of amniotic fluid is 7.0 to 7.6).
- Amniotic fluid should be assessed for meconium-stained fluid, other discoloration, etc.
