What is the first nursing action after a client's membranes rupture spontaneously?

Determining the fetal heart rate is the first nursing action after a client's membranes rupture spontaneously because it is crucial to assess the well-being of the fetus immediately. The rupture of membranes increases the risk of umbilical cord compression, infection, and changes in fetal heart patterns. By listening to the fetal heart rate, the nurse can detect any signs of fetal distress and initiate timely interventions if necessary. Monitoring the fetal heart rate provides essential information about how the fetus is responding to the changes in the environment, allowing for prompt management to ensure the safety of both the mother and the baby.

While assessing for signs of labor, checking maternal vital signs, and notifying the physician are also important actions to take after membranes rupture, the priority is to evaluate fetal status first. This helps in forming an accurate clinical picture and determining the need for potentially immediate interventions.