A nurse is assessing a client who is 6 hours postpartum, tachycardic, and has cool skin. The client reports that they have been bleeding excessively.
Which of the following actions should the nurse take?

Choice A rationale

In the scenario of ruptured membranes with a breech presentation, there is an elevated risk of umbilical cord prolapse due to the disproportionate fit of the presenting part in the maternal pelvis. Checking fetal heart tones immediately allows for rapid detection of cord compression, which manifests as abrupt decelerations, indicating fetal distress and necessitating urgent intervention.

Choice B rationale

While a cesarean birth is often indicated for breech presentations, especially with ruptured membranes, it is not the immediate first action. The priority is to assess fetal well-being, specifically ruling out umbilical cord prolapse, as this is an acute emergency that requires immediate intervention to prevent fetal hypoxia and mortality, prior to surgical preparation.

Choice C rationale

Assessing the color, amount, and odor of the amniotic fluid provides information about potential infection or meconium presence, which are important data points. However, the immediate life-threatening complication with ruptured membranes and breech presentation is umbilical cord prolapse, making fetal heart tone assessment a more urgent priority.

Choice D rationale

Performing a Nitrazine test confirms the rupture of membranes, but the client has already reported "my water just broke.”. While a confirmatory test, it is not the immediate priority. The critical concern is the potential for umbilical cord prolapse, which directly impacts fetal oxygenation and requires immediate assessment via fetal heart tones.

Choice A rationale

A BUN level of 25 mg/dL is above the normal range of 10 to 20 mg/dL for pregnant clients. Elevated BUN can indicate impaired renal function, which can be a complication of pregnancy, particularly in conditions like preeclampsia or underlying kidney disease. This finding, especially in a client with a history of anemia, warrants further investigation as it suggests potential kidney compromise affecting waste product excretion.

Choice B rationale

A hemoglobin (Hgb) level of 10.2 mg/dL is slightly below the normal range of 11 to 16 mg/dL for pregnant clients. Given the client's history of anemia, this finding is consistent with their known condition and, while it indicates mild anemia, it might not necessarily represent a new acute prenatal complication requiring immediate report unless there is a significant drop or associated symptoms. Iron supplementation is typically initiated for this level.

Choice C rationale

A fasting blood glucose of 70 mg/dL is within the normal range of 70 to 110 mg/dL. This indicates adequate glucose regulation and does not suggest a prenatal complication such as gestational diabetes. Maintaining a normal fasting blood glucose is a positive indicator for maternal and fetal well-being, especially for a client without a history of diabetes.

Choice D rationale

A hematocrit (Hct) level of 32% is slightly below the normal range of 33 to 47% for pregnant clients. Similar to hemoglobin, a slightly low hematocrit is common in pregnancy due to hemodilution, where plasma volume increases more significantly than red blood cell mass. While it indicates mild physiological anemia, it is often managed with dietary adjustments or iron supplements and does not typically signify an acute prenatal complication requiring immediate report.