Question

A nurse is admitting a client to the labor and delivery unit when the client states, "My water just broke." What intervention is the nurse's priority?

a) Assessing fetal heart rate
b) Monitoring contractions
c) Performing a sterile vaginal examination
d) Administering oxytocin

Answer 1

The nurse's priority intervention when a client's water breaks is to assess the fetal heart rate to ensure the fetus’s wellbeing. Pitocin is administered to Janine to induce or strengthen labor contractions because her labor was not progressing naturally.

Step-by-step explanation:

When a client states, "My water just broke," the nurse's priority intervention should be a) Assessing fetal heart rate. This initial assessment is crucial because it provides immediate information about the fetus's wellbeing following the rupture of the amniotic sac. Monitoring the fetal heart rate helps to identify any potential distress or abnormalities that could indicate complications requiring urgent attention.

In the context provided, Janine is admitted with mild, irregular contractions, and Pitocin is started because she is past her due date, and her labor is not effectively progressing. Pitocin is a synthetic form of oxytocin, which is used to induce or strengthen labor contractions, assisting in the progression of labor when necessary.