Final answer:
Upon the rupture of the amniotic sac, a nurse should initially assess the amniotic fluid for any signs of distress or infection. They should also monitor the mother’s and fetal vital signs and document the event, alerting the healthcare team if any concerns arise.
Step-by-step explanation:
When a laboring patient's water breaks, the first action a nurse should take is to assess the color, odor, amount of fluid, and the time of rupture. This is essential to determine if there are any signs of fetal distress or infection, such as a foul odor or greenish color indicating meconium (the baby's first stool), which can suggest fetal distress. The nursing team should also monitor the mother’s vital signs and the fetal heart rate to ensure that both are stable. Further, documentation of the event in the patient’s medical records is crucial. If there is any concern about the wellbeing of the mother or the baby, or if the fluid is discolored or has a foul odor, the healthcare team should be alerted immediately.
It is important to note that the amniotic sac breaking, also known as spontaneous rupture of membranes (SROM), can lead to the onset of labor if it has not already started. The nurse’s role includes supporting the patient through the stages of labor that follow, which begins with the cervix thinning and dilating, proceeding through the expulsion of the baby, and ending with the delivery of the placenta.