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Practice Question

A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction.  What would the nurse do next? 

Answer Choices:

Correct Answer:

Check the fetal heart rate.

Rationale:

🌟 After rupture of membranes, the priority is to assess fetal well-being by checking the fetal heart rate (FHR) to detect signs of umbilical cord prolapse or fetal distress, which can occur when the cord slips through the cervix after fluid loss.

🌟 The fetal heart rate should be assessed immediately following spontaneous rupture to rule out bradycardia, a potential sign of cord compression.

🌟 Although notifying the provider and changing the linen may be appropriate actions, they are not priority over checking the FHR, which ensures the baby's oxygenation status.

🌟 A vaginal exam should be avoided until fetal well-being is confirmed, especially if cord prolapse is suspected.

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This question is from Southeastern College Maternity exam which contains 54 questions.

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Southeastern College Maternity exam

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Question Details
  • Category: RN Nursing Exam(s)
  • Subcategory: General Exams
  • Domain: 🤱🏼Maternity & Newborn Care
  • Answer Choices: 4
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