Question

The nurse is caring for a woman in the first stage of labor. The fetal position is left occiput anterior. When her membranes rupture, the appropriate nursing actions would be to?

1) Assess the fetal heart rate
2) Evaluate color/clarity of amniotic fluid
3) Measure the amount of fluid
4) Notify the MD
5) Perform a vaginal exam

Answer 1

Upon amniotic membrane rupture, nurses should first assess the fetal heart rate and evaluate the color and clarity of the amniotic fluid, then notify the MD. Other actions, such as measuring fluid amount and vaginal exams, may be conducted as per clinical guidelines.

Step-by-step explanation:

When the amniotic membranes rupture, typically at the end of the dilation stage before the expulsion stage of labor, the appropriate nursing actions include several immediate steps. Firstly, the nurse should assess the fetal heart rate to ensure the fetus is not in distress following the rupture. Secondly, they should evaluate the color and clarity of the amniotic fluid, as the presence of meconium or unusual color can indicate fetal distress or infection. Additionally, it is important to notify the healthcare provider (MD), although assessing the immediate well-being of the fetus and the amniotic fluid characteristics take precedence over measuring the amount of fluid or performing a vaginal exam at that very moment. These latter steps may be indicated later, as directed by clinical guidelines and the MD's discretion.