The physician performs an amniotomy on a laboring woman. What will be the nurse's priority assessment immediately following this procedure?

Choice A rationale Maternal blood pressure should be assessed regularly, but immediately following amniotomy, it is not the highest priority. There is a slight risk of maternal hypotension due to a sudden decrease in uterine volume, but the more immediate and severe risk is to the fetus from potential umbilical cord complications that can happen right after fluid is released. Choice B rationale The amount of fluid released is documented as part of the procedure, providing information about total amniotic fluid volume (normal volume at term is approximately 700 to 1000 mL). While important for documenting potential oligohydramnios or polyhydramnios, it does not address the immediate, critical risk to the fetus's oxygen supply. Choice C rationale An amniotomy creates a risk of umbilical cord prolapse, where the umbilical cord is washed down with the fluid and compressed between the presenting fetal part and the cervix. This compression causes an immediate, severe drop in fetal oxygenation and manifests as fetal bradycardia or variable decelerations (normal FHR 110-160 bpm). Assessing the Fetal Heart Rate (FHR) is the priority to detect this acute emergency. Choice D rationale Deep tendon reflexes (DTRs) are assessed primarily to monitor for magnesium sulfate toxicity in clients being treated for preeclampsia/eclampsia. DTRs are not acutely affected by an amniotomy and are not part of the immediate post-procedure assessment protocol; thus, they are not the priority.