Question

A nurse is admitting a client to the labor and delivery unit when the client 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 nurse's priority when a client's water breaks is to assess the fetal heart rate to ensure the fetus is not in distress. Other assessments follow this initial step.

Step-by-step explanation:

When a client states that their 'water just broke' the nurse's priority is assessing fetal heart rate (A). This step is critical to ensure that the fetus is not in distress, particularly following the rupture of the membranes. Other steps such as checking the cervical dilation (B), providing pain relief measures (C), and verifying the amniotic fluid color (D) are also important but come after ensuring the immediate well-being of the fetus through heart rate assessment.