A client at 40-weeks gestation arrives at the obstetrical floor and reports that her amniotic membranes ruptured spontaneously at home.
She is in active labor and feels the need to bear down and push. What is the most important information for the nurse to obtain?

Choice A rationale

While the estimated amount of fluid can provide some information about the volume of amniotic fluid lost, it is not the most critical piece of information. The amount of fluid can vary and does not necessarily indicate the progression of labor.

Choice B rationale

Any odor noted when the membranes ruptured can be a sign of infection. However, this is not the most crucial information to obtain immediately as it does not directly impact the management of labor.

Choice C rationale

The time the membranes ruptured is the most important information to obtain. This is because the risk of infection increases the longer the time between membrane rupture and delivery.

Knowing the time of rupture helps guide decisions about inducing labor and administering antibiotics to prevent infection.

Choice D rationale

The color and consistency of the fluid can provide information about the presence of meconium or blood, which could indicate fetal distress or placental problems. However, this is not the most critical information to obtain immediately.

Answer: D. Sit the newborn upright and burp by gently rubbing or patting the upper back.

Rationale:

• Choice A: Clean up the spit-up and assist the mother with the diaper change is not the first priority. While cleaning is important, ensuring the baby's airway is clear and preventing aspiration (inhaling vomit into the lungs) is more critical.
• Choice B: Position the newborn on the side and suction the mouth and nares with a bulb syringe is only necessary if the baby shows signs of respiratory distress, such as coughing, wheezing, or difficulty breathing. Unless aspiration is suspected, suctioning can irritate the nasal passages and worsen the situation.
• Choice C: Position the newborn with the head lower than the feet can actually increase the risk of aspiration. Fluids can pool in the back of the throat and be more easily inhaled.
• Choice D: Sit the newborn upright and burp by gently rubbing or patting the upper back is the most appropriate first action. This position helps bring up any air swallowed during feeding, reducing the likelihood of spitting up. Gently rubbing or patting the back encourages the burp reflex.

Additional Notes:

• After burping the baby, the nurse can assess the amount of spit-up and clean the baby and surrounding area as needed.
• If the baby shows signs of respiratory distress after burping, suctioning may be necessary. However, this should only be done by a healthcare professional.
• If the spitting up is frequent or forceful, the nurse should consult with a doctor to rule out any underlying medical conditions.