Question

A nurse is admitting a client to the L&D unit when the client states, "My water just broke." Which of the following interventions is the nurse's priority?

A. Administering pain medication
B. Monitoring fetal heart rate
C. Preparing for a cesarean birth
D. Assessing cervical dilation

Answer 1

The nurse's priority intervention when a client's water breaks during admission to the L&D unit is to monitor fetal heart rate.

Step-by-step explanation:

The nurse's priority intervention when a client's water breaks during admission to the L&D unit is to monitor fetal heart rate (Option B).

Monitoring the fetal heart rate is essential to assess the well-being of the baby and to determine if any distress is present. It allows the nurse to detect any changes in the baby's heart rate that may require urgent intervention.

Administering pain medication (Option A), preparing for a cesarean birth (Option C), and assessing cervical dilation (Option D) can be important interventions but are not the priority when the client's water breaks.