A nurse is caring for a client who is postpartum, has a deep-vein thrombosis, and is receiving heparin therapy via subcutaneous injections. Which of the following actions should the nurse take?

Assess the fetal heart rate pattern.

Choice B rationale:

When a laboring client's membranes have just ruptured, the nurse's next action should be to assess the fetal heart rate pattern. Rupture of membranes can lead to changes in amniotic fluid, which can affect the fetal environment and potentially cause fetal distress. By assessing the fetal heart rate pattern, the nurse can determine if the baby is tolerating the labor process well or if there are signs of fetal compromise that require further intervention.

Choice A rationale:

While assessing the client's blood pressure (Choice A) is important during labor, it is not the immediate next action when the membranes have ruptured.

Choice C rationale:

Taking the client's temperature (Choice C) is also important, but it is not the priority action when the membranes have ruptured.

Choice D rationale:

Preparing for a c-section (Choice D) is not the initial action unless there are specific indications for an emergency cesarean section. Assessing the fetal heart rate is more critical at this stage.

Choice A rationale:

This finding may indicate a neurological problem or an issue with the baby's ability to feed, which can lead to inadequate nutrition and hydration. It's essential for the newborn to establish good feeding patterns early on

Choice B rationale:

Blue coloring of the hands and feet, also known as acrocyanosis, is a common and normal finding in newborns. It results from the immaturity of the peripheral circulation and usually resolves on its own without any intervention.

Choice C rationale:

A soft, edematous area on the scalp, also known as caput succedaneum, is a common finding following vacuum-assisted delivery and typically resolves without intervention.

Choice D rationale:

Facial edema is another common finding in newborns, especially after vacuum-assisted deliveries. It is typically a transient and self-resolving condition that does not require immediate intervention or reporting to the provider.