Final answer:
The priority nursing action after rupture of membranes is to assess fetal heart rate, as it is essential to monitor for signs of fetal distress immediately following the rupture. Other subsequent actions include administering oxytocin if needed, monitoring the mother's vital signs, and documenting the amniotic fluid characteristics.
Step-by-step explanation:
The priority nursing action after spontaneous or artificial rupture of membranes is to assess fetal heart rate. This is critical because the rupture can alter the pressure in the uterus and stress the fetus, potentially leading to changes in heart rate which need to be monitored immediately for signs of fetal distress. Interventions such as administering oxytocin, monitoring vital signs, and documenting characteristics of amniotic fluid would follow this initial assessment, based on the specific circumstances and protocols of the healthcare institution.
In cases of Preterm Premature Rupture of Membranes (PPROM), which can occur before 38 weeks of gestation due to factors such as bacterial infection or defects in the amniotic sac, it's essential to manage the risks associated with potential infection and labor progression. Post-delivery, examining the expelled placenta and fetal membranes ensures that they are intact to prevent complications like postpartum hemorrhage. Additionally, observing amniotic fluid characteristics can provide information about possible infections or meconium, which is the baby's first stool, potentially present in the fluid.
After rupture of membranes at term, known as 'spontaneous rupture of membranes’ (SROM), or before term, referred to as 'premature rupture of membranes' (PROM), the priority is the health and safety of both the mother and fetus. Monitoring the fetal heart rate is a crucial step to ensure the fetus is tolerating the labor process well.