Immediately after the rupture of membranes (either spontaneously or artificially), it is most important for the nurse to:
a. assess the fetal heart rate (FHR) for a full minute, and report significant changes
b. change the linen savers under the client's hip
c. note the color, quantity, and odor, and document on the chart
d. perform a vaginal examination to check for a prolapsed umbilical cord
A
After the rupture of membranes, there exists the danger that the umbilical cord will wash out with the amniotic fluid. The nurse should assess the fetal heart rate (FHR) for a full minute and report significant changes to ensure the cord is not occluded.
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