Difficulty: Medium
Average Score: 77%
Simulated
While the nurse is caring for a multiparous client in active labor at 36 weeks' gestation, the client tells the nurse, 'I think my water just broke.' Which of the following should the nurse do first?
Correct answer
C
Rationale
Rupture of membranes can affect fetal well-being, particularly in preterm labor (36 weeks). Assessing the fetal heart rate pattern first ensures the fetus is not in distress (e.g., due to cord compression). Fluid characteristics and dilation are assessed next.