NCLEX-RN · Question #228
A pregnant client experiences spontaneous rupture of membranes. The first nursing action is to:
The correct answer is C. Auscultate fetal heart rate. (A) Immediately following membrane rupture, the fetus is at risk for complications, not necessarily (B) The physician is notified after the nurse completes an assessment of the mother's and fetus's (C) Rupture of membranes facilitates fetal descent. A potential complication is…
Question
A pregnant client experiences spontaneous rupture of membranes. The first nursing action is to:
Options
- AAssess the client's respirations
- BNotify the physician
- CAuscultate fetal heart rate
- DTransfer to delivery suite
How the community answered
(48 responses)- A10% (5)
- B2% (1)
- C73% (35)
- D15% (7)
Explanation
(A) Immediately following membrane rupture, the fetus is at risk for complications, not necessarily (B) The physician is notified after the nurse completes an assessment of the mother's and fetus's (C) Rupture of membranes facilitates fetal descent. A potential complication is cord prolapse, which is assessed by auscultating fetal heart rate. (D) Rupture of membranes does not necessarily indicate readiness to deliver.
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