Question

The client comes to the hospital in labor. The membranes rupture at 0410. Which action does the nurse take first?

A. Assess the fetal heart rate.
B. Administer oxytocin.
C. Check for meconium in the amniotic fluid.
D. Monitor maternal vital signs

Answer 1

The nurse's first action when the client comes to the hospital in labor and the membranes rupture is to assess the fetal heart rate. So, the correct answer is C. Check for meconium in the amniotic fluid.

Step-by-step explanation:

The nurse's first action when the client comes to the hospital in labor and the membranes rupture is to assess the fetal heart rate. This is important to determine the well-being of the baby and to ensure that there are no signs of distress. By assessing the fetal heart rate, the nurse can make appropriate decisions regarding the next steps in care.

So, the correct answer is C. Check for meconium in the amniotic fluid.

Answer 2

The nurse's initial priority should be to assess the fetal heart rate as the membranes have ruptured, ensuring the well-being of the baby during labor. This information guides subsequent interventions and care decisions.

A. Assess the fetal heart rate.

Step-by-step explanation:

When a client arrives at the hospital in labor with ruptured membranes, the nurse's first action should be to A. assess the fetal heart rate (FHR). This is crucial as it provides immediate insights into the well-being of the unborn child. Monitoring the FHR allows the nurse to evaluate the baby's response to the labor process and ascertain whether there are any signs of distress or compromise. A normal FHR range is indicative of fetal well-being, while deviations may signal potential complications, such as fetal distress or hypoxia.

Assessing the FHR promptly enables the healthcare team to make informed decisions about the course of action during labor. If abnormalities are detected, interventions may be necessary to address the underlying issues and ensure the safety of both the mother and the baby. Additionally, assessing the FHR aligns with the principles of fetal monitoring during labor, which is a standard practice in obstetric care.

While other actions, such as monitoring maternal vital signs, checking for meconium in the amniotic fluid, and administering oxytocin, are important aspects of labor management, assessing the fetal heart rate takes precedence in this context due to its immediate relevance to the well-being of the unborn child. So correct option is A. Assess the fetal heart rate.