NCLEX RN Exam Questions Practice Question
A client's membranes have just ruptured spontaneously. Which of the following nursing actions should take priority?
Correct Answer: D
Rationale: If changes in the FHR are noted, the nurse should check for umbilical cord prolapse. This intervention has priority over the other actions. The danger of a prolapsed cord is increased once membranes have ruptured, especially if the presenting part of the fetus does not fit firmly against the cervix.
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