The laboring client presses the call light and reports that her water has just broken. The nurse's first action would be to:
1. Check fetal heart tones.
2. Encourage the mother to go for a walk.
3. Change bed linen.
4. Call the physician.
1
Rationale:
1. Fetal heart tones should be checked after rupture of the membranes to assess for cord compression.
2. If the presenting part is not engaged, the laboring client should not be allowed to walk, because there is a risk of cord prolapse once the membranes have ruptured.
3. The bed linen can be changed after assessing the heart rate.
4. The physician does not need to be called after rupture of the membranes unless there is a change in status of the fetus or client.
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