During the active stage of labor, a patient's membranes spontaneously rupture. Which action should the nurse do first after this occurs?
A) Turn the patient onto the left side.
B) Assess fetal heart rate for fetal safety.
C) Test a sample of amniotic fluid for protein.
D) Instruct to bear down with the next contraction.
B
Feedback:
If membranes rupture during labor, the fetal heart rate should be assessed immediately to be certain that the umbilical cord hasn't prolapsed and is now being compressed against the cervix by the fetal head. The patient does not need to be turned onto the left side. The amniotic fluid is tested for pH and not protein. Bearing down at this time could be dangerous, considering there is no way of knowing how much the cervix has dilated at the time of membrane rupture.
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