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A client in active labor who's vaginal exam 1 hr ago showed that she was 3 cm dilated, 50 percent effaced, and had a - 3 station. Her membranes ruptured spontaneously. The nurse should assess her for which sign?

a) Increased fetal heart rate
b) Decreased contractions
c) Prolapsed cord
d) Meconium-stained amniotic fluid

User Ferdau
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Final answer:

The nurse should assess for the sign of a prolapsed cord after the spontaneous rupture of membranes in an active labor client, as it is an emergency condition which requires immediate medical attention.

Step-by-step explanation:

When a client in active labor experiences spontaneous rupture of membranes (SROM), also known as "breaking of the water", the nurse should assess for the sign of a prolapsed cord. This is because the rupture can cause the umbilical cord to suddenly drop and become trapped against the baby's body, leading to a decrease in blood flow to the fetus. A prolapsed cord is an emergency that requires immediate medical intervention to ensure the safety of the fetus. Other signs such as increased fetal heart rate, decreased contractions, or meconium-stained amniotic fluid are possibilities after rupture, but the presence of a prolapsed cord is a critical complication that must be ruled out first.

User Mande
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