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19 February, 06:24

While a 31-year-old multigravida at 39 weeks' gestation in active labor is being admitted, her amniotic membranes rupture spontaneously. the client's cervix is 5 cm dilated, the presenting part is at 0 station, and the electronic fetal heart rate pattern is reassuring. what should the nurse do first?

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  1. 19 February, 06:34
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    The nurse should first note the amount, color as well as the odor of the amniotic fluid.

    Explanation

    When a patient’s membrane ruptures spontaneously, the nurse should start by checking the consistency, odor, as well as the volume of the amniotic fluid. For this case, there are minimal chances of cord prolapse because the fatal head is already engaged and at 0 station. If the fatal head is not yet engaged, the nurse should start by checking for cord prelapse if the membrane ruptures spontaneously.
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