Question

While a nurse is caring for a multiparous client in active labor at 36 weeks gestation, the client tells the nurse "I think my water just broke" What should the nurse do first?

1. Turn the client to the right side
2. Assess the color amount and odor of the fluid
3. assess the FHR pattern
4. Check the clients cervical dilation

Answer 1

The nurse should first assess the fetal heart rate (FHR) pattern when a client reports the rupture of the amniotic sac, to monitor the well-being of the fetus.

Step-by-step explanation:

When a multiparous client at 36 weeks gestation tells the nurse that her water might have just broken, the nurse should first assess the fetal heart rate (FHR) pattern. Monitoring the FHR is crucial for determining the well-being of the fetus, especially after the rupture of membranes, which can lead to changes in fetal circulation. After this initial assessment, the nurse should then assess the color, amount, and odor of the fluid to check for signs of infection or meconium, which could suggest fetal distress.

When a client in active labor at 36 weeks gestation says that her water just broke, the nurse should first assess the color, amount, and odor of the fluid. This is important because the color, amount, and odor of the amniotic fluid can provide valuable information about the health of the baby and the risk of infection. The nurse should also assess the FHR pattern to ensure that the baby's heart rate is within a normal range. Turning the client to the right side is not the priority in this situation.