Difficulty: Medium
Average Score: 80%
Simulated
A primigravid client at 34 weeks' gestation is experiencing contractions every 3 to 4 minutes lasting for 35 seconds. Her cervix is 2 cm dilated and 50% effaced. While the nurse is assessing the client's vital signs, the client says, "I think my bag of water just broke." Which of the following would the nurse do first?
Correct answer
A
Rationale
Checking the fetal heart rate is the first action to ensure fetal well-being.