MEDizzy - The membranes of a client who is at 39 weeks’ gestation have

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Nursing Care for Uncomplicated Pregnancy Labor & Post-partum

The membranes of a client who is at 39 weeks’ gestation have ruptured spontaneously. Examination in the emergency department revealed that her cervix is 4 cm dilated and 75% effaced, and the fetal heart rate is 136 beats/min. She and her partner are admitted to the birthing unit. What should the nurse do upon their arrival?

ExplanationC. The client is in the first stage of labor; she and the fetus were assessed earlier and both are stable. At this time the priority of care is to establish a trusting relationship with her and her partner. This will help to allay their anxiety. A. This may be necessary later; however, it is not the priority. B. The history should be taken from the client as long as she is capable of providing it. D. This is not a priority; the health care provider may have been notified already.