The most immediate nursing intervention after a suspected rupture of membranes is to assess the fetal heart rate (FHR). This is the priority because of the risk of umbilical cord prolapse. When the membranes rupture, the umbilical cord can be washed down with the gush of fluid and become compressed between the fetal presenting part and the maternal pelvis. This compression obstructs blood flow and oxygen to the fetus, which is immediately reflected in the FHR as bradycardia or severe variable decelerations. Assessing the FHR is the fastest way to determine fetal well-being and identify this life-threatening emergency.

A. Noting the fluid is an important assessment but is secondary to evaluating fetal status. Fetal well-being is the highest priority.

C. The physician must be notified, but the nurse should first perform a critical assessment to provide accurate, up-to-date information, such as the FHR.

D. Confirming the rupture of membranes with a nitrazine test is appropriate but not the first priority. The immediate risk to the fetus must be assessed first.

1. Lowdermilk, D. L., Perry, S. E., Cashion, K., & Alden, K. R. (2020). Maternity and Women's Health Care (12th ed.). Elsevier. In Chapter 16, "Labor and Birth Processes," under the section "Rupture of Membranes," the text states, "The first priority of care after the membranes rupture is to assess the FHR and pattern" (p. 381).

2. National Council of State Boards of Nursing (NCSBN). (2022). 2023 NCLEX-RN® Test Plan. This question aligns with the Client Needs Category "Reduction of Risk Potential," which requires the nurse to "identify acute, life-threatening complications" and "initiate immediate interventions." Assessing FHR post-ROM is a key intervention to mitigate the risk of fetal compromise (p. 21).

3. Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). (2021). Fetal Heart Monitoring Principles and Practices (6th ed.). Kendall Hunt Publishing. Chapter 4 discusses the evaluation of fetal well-being and emphasizes that events like rupture of membranes are critical points for FHR assessment to detect potential cord compression events.