NCLEX Question for Active Labor at 4cm dilated 100% effaced, 0 station

Mrs.  B. is in active labor at 4 cm dilated, 100% effaced, and 0 station.  As she is ambulating she experiences a gush of fluid. What is the most appropriate initial action for the nurse to take?

a.    Send a specimen of the amniotic fluid to the laboratory for analysis.,

b.    Have Mrs. B. return to her room and place her in Trendelenburg position to prevent cord prolapse.

c.    Have Mrs. B. return to her room so that you can assess fetal status, including auscultation of fetal heart tones for one full minute.

d.    Call Mrs. B.’s physician because a cesarean delivery will be required.

Correct Answer: C. The most important nursing action after rupture of the membranes is careful fetal assessment, including fetal heart tones counted for one minute.

There is no known reason based on the available information to request amniotic fluid analysis.  Therefore, not only is this not an appropriate initial action, it is not required at all.

The presenting part is at 0 station.  At this station, it is unlikely that a cord prolapse would occur.  

 Trendelenburg would be sued only if an assessment confirmed this complication.

There is no information suggesting that Mrs. B. will require operative delivery.  It is more important to assess the client than anything else at this time.

Posted in: MCN NCLEX