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Difficulty: MediumAnte/Intra/Postpartum and Newborn Care

An obstetrical nurse is admitting a multigravida client at 39 weeks of gestation who reports a sudden gush of clear fluid from the vagina while walking in the hospital corridor. Which action must the nurse perform first?

  1. Assess the fetal heart rate pattern using a monitor or Doppler.Answer
  2. B
    Perform a sterile vaginal examination to evaluate cervical dilation.
  3. C
    Instruct unlicensed assistive personnel (UAP) to assist the client to the bathroom.
  4. D
    Position the client in an upright wheelchair to transport them to a labor room.

Answer

Assess the fetal heart rate pattern using a monitor or Doppler.
When the amniotic membranes rupture, there is a significant risk that the umbilical cord may be washed down with the fluid, leading to an umbilical cord prolapse. This obstetric emergency compresses the cord and compromises fetal oxygenation. Assessing the fetal heart rate immediately detects sudden decelerations or bradycardia indicative of a prolapse, making it the absolute highest priority.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has experienced spontaneous rupture of membranes (SROM) while ambulatory.
Identifying the event (SROM) helps determine the physiological risks, primarily the risk of the umbilical cord prolapsing with the gush of fluid.
2
Determine the most immediate life-threatening complication associated with the event.
Umbilical cord prolapse is the most immediate threat, as it can cause sudden fetal hypoxia.
Prioritization requires addressing airway, breathing, and circulation (ABC) needs first. For a fetus, the fetal heart rate is the primary indicator of adequate circulation and oxygenation.
3
Select the nursing intervention that directly assesses this priority.
Assessing the fetal heart rate is selected as the first action.
Evaluating the fetal heart rate will immediately reveal if cord compression (indicated by sudden bradycardia or profound variable decelerations) has occurred.

Key Concept

Prioritization of Care Following Rupture of Membranes
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Topics

Ante/Intra/Postpartum and Newborn Care

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