A multiparous client has been in labor for 8 hours when her membranes rupture. What action should the nurse implement first?

• A. Prepare the client for imminent birth.
• B. Assess the fetal heart rate and pattern.
• C. Document the characteristics of the fluid.
• D. Notify the client's primary healthcare provider.

Answer: (B)

After membranes rupture, the top priority is to determine how the fetus is tolerating labor. Checking the fetal heart rate and pattern right away gives immediate information about fetal oxygenation and potential distress, which guides the next steps. Baseline rate, variability, accelerations, and decelerations help identify concerns such as cord compression or uteroplacental insufficiency so you can intervene promptly if needed. Other actions like preparing for birth, documenting the fluid, or notifying the provider are important, but they hinge on what the fetal heart rate shows—fetal status comes first in this moment.