After rupture of membranes, if the amniotic fluid is clear and may contain vernix, what should the nurse do?

• A. Obtain a sample of the amniotic fluid for laboratory analysis
• B. Check the client's temperature
• C. Document the findings
• D. Report the findings to the nurse-midwife

Answer: (C)

When membranes rupture, the nurse’s first priority after observing the fluid is to record what’s seen. Clear amniotic fluid with possible vernix is a normal-looking finding, and documenting the exact color, presence of vernix, amount, and the time of rupture creates a precise baseline for ongoing assessment. This documentation supports continuity of care and helps the team monitor for any changes that might indicate infection or other complications. While ongoing care includes monitoring temperature and communicating with the nurse‑midwife as needed, the essential immediate action in this scenario is to document the findings so the care plan can be accurately updated.