VATI RN Maternal Newborn Assessment Practice Exam

Checking fetal heart tones is the most critical action to take first when a client in active labor reports that her water has broken and the baby is in a breech presentation. This is essential for several reasons.

Firstly, a breech presentation can pose risks for the fetus during labor, including the potential for cord prolapse and fetal distress. By assessing fetal heart tones, the nurse can quickly determine if the fetus is in distress or if there are any anomalies in the fetal heart rate pattern that would necessitate urgent intervention.

Fetal heart monitoring allows the healthcare provider to ensure continuous assessment of the fetus's well-being, which is paramount in any labor scenario but especially critical when complications like a breech presentation and ruptured membranes are involved. Depending on the findings from the fetal heart assessment, subsequent actions can be determined, such as preparing for a cesarean section if there are signs of fetal distress or cord involvement.

In this situation, while other assessments and interventions—such as checking contractions and administering IV fluids—are important, they do not take precedence over ensuring the immediate safety and well-being of the fetus. Hence, checking fetal heart tones should be the priority action in this context.