The nurse is caring for a client who is a gravida 5 in active labor. The membranes spontaneously rupture with a large amount of clear amniotic fluid. Which nursing action is most important to take at this time?
1. Perform a Leopold maneuver.
2. Complete a sterile vaginal examination.
3. Obtain an order for pain medication.
4. Assess the odor of the amniotic fluid.
2
Explanation:
1. This assessment is not called for at this time.
2. Checking the cervix will determine whether the cord prolapsed when the membranes ruptured. A prolapsed cord leads to rapid onset of fetal hypoxia, which can lead to fetal death within minutes if not treated.
3. Pain medication is a low priority at this time.
4. Although it is important to assess amniotic fluid for odors, checking the cervix to assess for cord prolapse is a higher priority.
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