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    Ati rn maternal newborn 2023 proctored exam

    A nurse is admitting a client who is at 39 weeks of gestation and who states, "My water broke on the way to the hospital." Which of the following actions should the nurse take first?

    Explanation & Rationale

    A. Monitoring cervical dilation is important but not the immediate priority. B. Asking about the color of the amniotic fluid helps assess for meconium but is secondary. C. Vaginal pH testing can help confirm rupture but is not the first action. D. Determining the fetal heart rate is the priority to assess for signs of fetal distress immediately after rupture of membranes.

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