What is the first action a nurse should take when a client's membranes rupture and fetal heart rate is assessed?

When a client's membranes rupture, the first action a nurse should take is to check the character of the amniotic fluid. This assessment is crucial for several reasons.

Firstly, the nature of the amniotic fluid can provide important information about the condition of the fetus and the potential presence of complications. For example, if the fluid is clear, it may indicate a normal situation, whereas the presence of meconium-stained fluid could signal fetal distress.

Secondly, assessing the amniotic fluid helps to determine the risk of infection, as ruptured membranes can lead to complications such as chorioamnionitis if they are ruptured for an extended period before delivery. Identifying any abnormalities in the fluid allows the healthcare provider to address any issues promptly and ensure the safety of both the mother and the fetus.

While other actions such as preparing for delivery, assessing maternal vital signs, or documenting findings are also important steps in the management of a ruptured membrane situation, they should come after the initial assessment of the amniotic fluid. Checking the fluid's character provides immediate insight that guides subsequent nursing interventions.