When membranes rupture spontaneously at 5 cm with reassuring fetal status, what is the first assessment the nurse should perform?

• A. Note the color, amount, and odor of the amniotic fluid
• B. Check maternal blood glucose
• C. Initiate immediate cesarean planning
• D. Assess fetal head position with vaginal examination

Answer: (A)

When membranes rupture during active labor, the first thing to assess is the amniotic fluid itself. Inspecting the fluid for color, amount, and odor quickly signals whether there are concerns that would change management. Clear, odorless fluid in an adequate amount is reassuring, while meconium-stained fluid (greenish) can indicate fetal distress or post-term maturation, and a foul odor raises concern for chorioamnionitis. This initial fluid assessment helps determine the next steps, such as continuous fetal monitoring, maternal temperature checks, and closer observation for infection or distress. Other actions, like checking maternal glucose, initiating cesarean planning, or performing a vaginal exam immediately, are not the immediate priority given reassuring fetal status and ROM; they would be addressed based on the fluid findings and ongoing fetal monitoring.