The nurse’s initial action once the bag of water has ruptured is.. Put the client to the bed immediately

The nurse’s initial action once the bag of water has ruptured is:
a. Take the fetal heart tones
b. Put the client to the bed immediately
c. Perform an IE
d. Take the woman’s temperature

Answer: B.
The keyword is INITIAL ACTION. The important consideration before answering the question is to take a look at the situation. SITUATION: THE WOMAN IS IN THE Emergency Room or is seeking admission.
A woman in labor seeking admission to the hospital (in the ER) and saying that her BOW has ruptured should BE PUT TO BED IMMEDIATELY and the fetal heart tones taken consequently. If a woman in the Labor Room says that her membranes have ruptured, the initial nursing action is to take the fetal heart tone.