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    Hesi compass B exit proctored exam

    The nurse is receiving report for a laboring client who arrived in the emergency center with ruptured membranes that the client did not recognize. Which is the priority nursing action to implement when the client is admitted to the labor and delivery suite?

    Explanation & Rationale

    A. Monitoring amniotic fluid for meconium is important to assess for possible fetal distress but is not the first priority upon admission. B. Taking the client’s temperature is the priority because ruptured membranes increase the risk of intrauterine infection (chorioamnionitis), and an elevated temperature would require immediate intervention. C. Preparing to start an IV may be necessary for labor management but does not take precedence over assessing for signs of infection in this context. D. Beginning a pad count may help estimate fluid loss but is not as urgent as evaluating for infection risk.

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