Question

A nurse is admitting a client who states, 'my water just broke.' Which of the following interventions is the nurse's priority?

A) Assessing fetal heart rate.
B) Checking the cervical dilation.
C) Providing pain relief measures.
D) Verifying the amniotic fluid color.

Answer 1

The priority for a nurse when a client's water breaks is to assess the fetal heart rate to ensure the well-being of the fetus. Other examinations will follow according to the clinical protocol and patient needs. Pitocin may be given in cases where labor is not progressing effectively.

Step-by-step explanation:

The priority intervention for a nurse when a client reports that their water just broke is Assessing fetal heart rate (A). This action is crucial because it provides immediate information about the well-being of the fetus. It is essential to verify the fetal heart rate to ensure that the fetus is not in distress following the rupture of membranes.

After assessing the fetal heart rate, other actions like checking the cervical dilation, verifying the color of the amniotic fluid, and providing pain relief measures can follow as per the established clinical protocols and the patient's needs.

A nurse may initiate interventions such as Pitocin infusion when labor does not progress normally, to stimulate contractions and promote cervical dilation. This relates to Janine, who at 41 weeks had to receive Pitocin to aid in her labor due to insufficient dilation and mild, unproductive contractions.