When a patient states, "My water just broke," and the nurse confirms rupture of membranes, what is the next action?

When a patient reports that her water has broken, confirming the rupture of membranes indicates that the amniotic sac has released the fluid surrounding the fetus. The most immediate concern following this confirmation is assessing the fetal heart sounds.

Listening for fetal heart tones provides critical information about the well-being of the fetus and can identify any potential complications, such as fetal distress, immediately after the membranes rupture. Establishing the fetal heart rate is a priority because it informs further actions and interventions in the care of both the mother and the baby. If the heart rate is abnormal, it may indicate issues that need to be promptly addressed.

Following the initial assessment of fetal heart sounds, other actions may be necessary. These include preparing for potential delivery, checking for cord prolapse, and assessing the patient's pain level, but the immediate priority is to ensure the fetal heart rate is stable after the membranes have ruptured.