NCLEX Question for Ruptured Membranes Plan of Care

Mrs. M., a primigravida, presents to the labor room with rupture of membranes at 40 weeks gestation.  Her cervix is 2 cm dilated and 100% effaced.  Contractions are every 10 minutes.  What should the nurse include in the plan of care?
a.    Allow Mrs. M. to ambulate as desired as long as the presenting part is engaged.

b.    Assessed fetal heart tones and maternal status every five minutes.

c..    Place Mrs. M. on an electronic fetal monitor for continuous assessment of labor.

d.    Send Mrs. M. home with instructions to return when contractions are every five minutes.

Correct Answer A.. Ambulation will help Mrs. M.’s contractions more effectively dilate the cervix.  As long as the presenting part is engaged, there is not increased risk of cord prolapse.
 

Assessments every five minutes are made during the second stage of labor. They are not required during the latent phase of first stage labor.
 

Although periodic assessments of mother and fetus are required, continuous monitoring is not indicated.
 

Although many patients in latent phase are sent home with instructions to return when contractions become more frequent, Mrs. M.’s ruptured membranes are a contraindication to that action.

Posted in: MCN NCLEX