Question

A nurse is admitting a client to the labor and delivery unit when the client states, "My water just broke." Which of the following interventions is the nurse's priority? a) Perform Leopold maneuvers b) Assess the fetal heart rate c) Insert an IV catheter d) Prepare the client for an ultrasound

Answer 1

The priority nursing intervention after a client's water breaks is to assess the fetal heart rate to ensure fetal well-being.

Step-by-step explanation:

When a client states, "My water just broke," the nurse's priority intervention is to assess the fetal heart rate. This is crucial to ensure that the fetus is not in distress following the rupture of the amniotic sac. Other interventions, such as performing Leopold maneuvers, inserting an IV catheter, and preparing the client for an ultrasound, may follow based on the fetal heart rate assessment and the clinical situation.

Answer 2

When a client's water breaks, the nurse's priority intervention is to assess the fetal heart rate to ensure the baby is not in distress.

Step-by-step explanation:

If a client arrives at the labor and delivery unit and states, "My water just broke," the nurse's priority intervention is b) Assess the fetal heart rate. This assessment is critical to ensure that the fetus is not in distress, particularly after the amniotic sac has ruptured, which can result in changes in fetal pressure and potential complications. After verifying that the baby's heart rate is within a normal range, the nurse can perform other necessary tasks, such as preparing the mother for an ultrasound, inserting an IV catheter, and performing Leopold maneuvers, in no particular order.