Posted by: Pdfprep
Post Date: October 25, 2020
A pregnant client experiences spontaneous rupture of membranes.
The first nursing action is to:
A . Assess the client’s respirations
B . Notify the physician
C . Auscultate fetal heart rate
D . Transfer to delivery suite
Answer: C
Explanation:
(A) Immediately following membrane rupture, the fetus is at risk for complications, not necessarily the mother.
(B) The physician is notified after the nurse completes an assessment of the mother’s and fetus’s conditions.
(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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