A client's membranes have just ruptured spontaneously. Which of the following nursing actions should take priority?

Question

Options

• AAssess quantity of fluid.
• BAssess color and odor of fluid.
• CDocument on fetal monitor strip and chart.
• DAssess fetal heart rate (FHR).

• A
  5% (1)
• B
  5% (1)
• C
  11% (2)
• D
  79% (15)

Explanation

(A) Assessing the quantity of amniotic fluid is important as an indication of maternal fetal well- being, but it does not take priority over assessment of FHR. (B) Greenish-brown discoloration of amniotic fluid indicates presence of meconium. Foul odor may indicate presence of infection. Both of these are important assessment data, but they do not take priority over possible lifethreatening compression of the umbilical cord. (C) Documentation is important, but it does not take priority over the possible life-threatening compression of the umbilical cord. (D) If changes in the FHR are noted, the nurse should check for umbilical cord prolapse. This intervention has priority over the other actions. The danger of a prolapsed cord is increased once membranes have ruptured, especially if the presenting part of the fetus does not fit firmly against

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