Question

While the nurse is caring for a multiparous client in active labor at 36 weeks gestation, the

client tells the nurse, "I think my water just broke." What should the nurse do first?

Answer 1

The nurse should first confirm rupture of membranes through a physical examination and monitor the fetal heart rate and maternal vital signs after a multiparous client in active labor reports her water breaking at 36 weeks gestation.

Step-by-step explanation:

When a multiparous client in active labor at 36 weeks gestation informs the nurse that her "water just broke," the nurse should first confirm whether the amniotic sac has actually ruptured. Prompt assessment, including a physical examination, is important to confirm rupture of membranes and evaluate the color, odor, and amount of fluid, which can provide vital information about the well-being of the mother and fetus.

Once rupture of membranes is confirmed, it is essential to monitor fetal heart rate and maternal vital signs, to ensure that they are within normal ranges, and to minimize the risk of infection since the protective barrier of the amniotic sac is no longer present.

The nurse should then report the findings to the healthcare provider and prepare for the labor process as labor typically begins soon after the amniotic sac breaks. In cases like these, the progression of labor and the health of the mother and fetus must be closely monitored to ensure a safe delivery.