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?

Question

Quizplus · Accepted Answer

With the membranes spontaneously rupturing and a large amount of clear amniotic fluid, completing a sterile vaginal examination is the most important nursing action. This will allow the nurse to assess the progress of labor and determine the need for interventions such as augmentation or delivery. The Leopold maneuver would be more appropriate earlier in the labor process to determine fetal positioning. Obtaining an order for pain medication and assessing the odor of the amniotic fluid can be done after the vaginal exam.

The Nurse Is Caring for a Client Who Is a Gravida