NCLEX-RN · Question #596
A female client admitted to the labor and delivery unit thinks her bag of water "broke" approximately 2 hours ago. She is having mild contractions 5 minutes apart. The most immediate nursing…
The correct answer is B. Assess the FHR. (A) Amniotic fluid is generally pale and straw colored. Meconium- stained amniotic fluid would indicate a previous hypoxic episode. This intervention, though appropriate, is not the immediate (B) With rupture of the membranes, the umbilical cord may prolapse if the presenting…
Question
A female client admitted to the labor and delivery unit thinks her bag of water "broke" approximately 2 hours ago. She is having mild contractions 5 minutes apart. The most immediate nursing intervention would be to:
Options
- ANote the color and amount of fluid on her clothes.
- BAssess the FHR.
- CNotify the physician.
- DPlace the nitrazine test paper at the cervical os and note the color change.
How the community answered
(21 responses)- A5% (1)
- B76% (16)
- C5% (1)
- D14% (3)
Explanation
(A) Amniotic fluid is generally pale and straw colored. Meconium- stained amniotic fluid would indicate a previous hypoxic episode. This intervention, though appropriate, is not the immediate (B) With rupture of the membranes, the umbilical cord may prolapse if the presenting part does not fill the pelvis. Assessing FHR ascertains fetal well-being. (C) More information regarding fetal status and assessing for membrane rupture is needed prior to contacting the physician. (D) Nitrazine test paper differentiates amniotic fluid from urine. Amniotic fluid is normally alkaline in contrast to urine, which is acidic. This intervention, though appropriate, is not the immediate
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