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A client’s membranes have just ruptured spontaneously. Which of the following nursing actions should take priority?
A. Assess quantity of fluid.
B. Assess color and odor of fluid.
C. Document on fetal monitor strip and chart.
D. Assess fetal heart rate (FHR).
Correct Answer: D
Explanation/Reference:
Explanation:
(A) Assessing the quantity of amniotic fluid is important as an indication of maternal fetal well- being, but it does not take priority over assessment of FHR. (B) Greenish-brown discoloration of amniotic fluid indicates presence of meconium. Foul odor may indicate presence of infection. Both of these are important assessment data, but they do not take priority over possible lifethreatening compression of the umbilical cord. (C) Documentation is important, but it does not take priority over the possible life-threatening compression of the umbilical cord. (D) If changes in the FHR are noted, the nurse should check for umbilical cord prolapse. This intervention has priority over the other actions. The danger of a prolapsed cord is increased once membranes have ruptured, especially if the presenting part of the fetus does not fit firmly against the cervix.
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