During early labor triage for a 38-week gestation patient with ruptured membranes and cervical dilation of 2 cm (70% effaced), what is the most appropriate initial nursing action?

• A. Obtain vital signs
• B. Apply external electronic fetal monitors for 20 minutes
• C. Begin antibiotics and IV fluids
• D. Discuss birth plan and analgesia preferences

Answer: (A)

Assessing maternal and fetal status begins with taking vital signs. This quick check provides a baseline and helps detect instability or infection signals (such as fever or tachycardia) that could indicate chorioamnionitis or other complications. If vitals are stable, you can proceed with further assessment like fetal monitoring and ongoing triage tasks; if there are abnormal signs, you escalate care promptly (antibiotics, IV fluids, urgent evaluation). Monitoring or discussing birth plans can come after establishing stability, but the first step is to know the patient’s current hemodynamic and infectious status through vital signs.