A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. The nurse's initial response would be to:
a. Prepare the woman for imminent birth.
b. Notify the woman's primary health care provider.
c. Document the characteristics of the fluid.
d. Assess the fetal heart rate and pattern.
ANS: D
The umbilical cord may prolapse when the membranes rupture. The fetal heart rate and pattern should be monitored closely for several minutes immediately after ROM to ascertain fetal well-being, and the findings should be documented. Rupture of membranes (ROM) may increase the intensity and frequency of the uterine contractions, but it does not indicate that birth is imminent. The nurse may notify the primary care provider after ROM occurs and fetal well-being and the response to ROM have been assessed. The nurse's priority is to assess fetal well-being. The nurse should document the characteristics of the amniotic fluid, but the initial response is to assess fetal well-being and the response to ROM.
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