The client in labor experiences a spontaneous rupture of ...

[ahriuashd]

The client in labor experiences a spontaneous rupture of membranes. What information related to this event must the nurse include in the client's record?
 
  a. Fetal heart rate
  b. Pain level
  c. Test results ensuring that the fluid is not urine
  d. The client's understanding of the event

Question 2

A nursing priority during admission of a laboring client who has not had prenatal care is:
 
  a. obtaining admission labs.
  b. identifying labor risk factors.
  c. discussing her birth plan choices.
  d. explaining importance of prenatal care.

[Brummell1998]

Answer to Question 1

ANS: A
Charting related to membrane rupture includes the time, FHR, and character and amount of the fluid. Pain is not associated with this event. When it is obvious that the fluid is amniotic fluid, which is anticipated during labor, it is not necessary to verify this by testing. The client's understanding of the event would only need to be documented if it presents a problem.

Answer to Question 2

ANS: B
When a client has not had prenatal care, the nurse must determine through interviewing and examination the presence of any pregnancy or labor risk factors, obtain admission labs, and discuss birth plan choices. Explaining the importance of prenatal care can be accomplished after the patient's history has been completed.