A nurse is caring for a woman in the first stage of labor. The fetal position is left occiput anterior. When her membranes rupture, the appropriate nursing actions would be to

assess the fetal heart rate
evaluate the color and clarity of amniotic fluid


• The first stage of labor is the longest and involves three phases:

  • Latent Phase: onset to 4 cm dilation/contractions 15 to 30 min apart, 15 to 30 secs long
  • Active Phase: 4 to 7 cm dilation/contractions 3 to 5 min apart, 30 to 60 secs long
  • Transition: 8 cm to fully dilated/10 cm/contractions 2 to 3 min apart, 45 to 90 secs long

• Counting the fetal heart rate before, during, and after contractions is important to ensure the well-being of the fetus. FHR should be 110 to 160 beats per minute. 

• Labor may begin with rupture of the membranes. If membranes rupture, first assess the FHR due to the risk of a collapsed umbilical cord. Then assess the color and clarity of the amniotic fluid to look for meconium staining, which would indicate fetal distress. Report any unusual findings immediately.

• The physician does not need to be notified unless there are unusual findings because spontaneous rupture of the membranes is an expected occurrence. An exception is if the color of the amniotic fluid is yellow, which may indicate a blood incompatibility between the mother and the fetus, or if the fluid is meconium-stained, i.e., dark-colored.

• Early rupture of the membranes can be advantageous if it causes the fetal head to settle snugly into the pelvis. However, intrauterine infection or prolapse of the umbilical cord are two risk factors associated with prolonged ruptured membranes during a long first stage of labor.

• Measuring the amount of fluid should only be done if the patient is experiencing oligohydramnios or hydramnios.

• Current clinical guidelines (Cochrane database) recommend keeping the number of vaginal examinations to a minimum to avoid promoting intraamniotic infection and for patient comfort. Routine VEs should only be performed on admission, every four hours in the first stage of labor, hourly in the second stage of labor, prior to administration of analgesia, and to evaluate for suspected complications.

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