Question

The nurse performs a vaginal examination for a laboring pt. The RN determines that the cervix is dilated 4 cm with 60% effacement, & the presenting part is at the -2 station. Thirty minutes later, the pt calls the RN & says, "I think my water just broke!" Which action has the highest priority?

A) Administer pain medication
B) Check fetal heart rate
C) Document the findings
D) Assess for meconium staining

Answer 1

The highest priority action when a laboring patient reports their water has broken is to check the fetal heart rate, ensuring the baby's well-being. Subsequently, the presence of meconium staining should be evaluated, followed by documentation of the findings, and managing pain as necessary.

Step-by-step explanation:

When the laboring patient reports that their water has just broken, the nurse's highest priority is to check the fetal heart rate (B). This is critical because the rupture of the membranes can lead to changes in the fetus's environment, such as a risk of compression of the umbilical cord, which could affect the baby's oxygen supply. It is also a point of transition that could indicate progression of labor, and the baby's vitals can provide immediate information about its well-being.

After assessing the fetal heart rate, the nurse should look for meconium staining (D) to ensure there is no fetal distress, as evidenced by the passage of meconium in the amniotic fluid. Documenting the findings (C) is an essential step to maintain accurate medical records. Finally, pain management (A) becomes a priority, but only after the other more critical assessments have been made to ensure the safety of both mother and child.