The physician performs an amniotomy on a laboring woman. What will be the nurse's priority assessment immediately following this procedure?
a. Fetal heart rate
b. Fluid amount
c. Maternal blood pressure
d. Deep tendon reflexes
ANS: A
The FHR should be assessed for at least 1 full minute after the membranes rupture and must be recorded and reported. Marked slowing of the rate or variable decelerations suggests that the fetal umbilical cord may have descended with the fluid gush and is being compressed. Fluid amount should be assessed and recorded but is not the top priority. Maternal blood pressure and deep tendon reflexes are not appropriate assessments following rupture of membranes.
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