Question

At 37 weeks' gestation, a client's membranes spontaneously rupture; however, she does not have any labor contractions. What action is most important in the nursing plan of care for this client?

A) Monitor for uterine contractions.
B) Administer pain medication.
C) Perform a cervical exam.
D) Administer oxytocin to induce labor.

Answer 1

The most important action to take for a client whose membranes have ruptured at 37 weeks' gestation without the onset of labor contractions is to monitor for uterine contractions.

Step-by-step explanation:

At 37 weeks' gestation, if a client's membranes spontaneously rupture but she does not have any labor contractions, the most important action in the nursing plan of care is to monitor for uterine contractions. This is crucial as the rupture of the amniotic membranes commonly occurs at the end of the dilation stage due to pressure from the fetal head entering the birth canal. Monitoring for contractions will help assess whether labor is progressing naturally. While performing a cervical exam is important to assess dilation and effacement, it is secondary to monitoring for contractions. Administering pain medication is not a priority if the client is not in active labor, and oxytocin should only be given after careful evaluation by the healthcare provider as it is used to induce or augment labor if necessary.