Question

a nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. the nurse determines the clients temperature is 38.9° c (102° f). besides notifying the provider, which of the following is an appropriate nursing action?

recheck the clients temperature in 4 hr.
prepare the client for emergency cesarean section.
administer glucocorticoids intramuscularly.
assess the odor of the amniotic fluid.

Explanation:

Analyze the clinical presentation

A client at 38 weeks of gestation in early labor with ruptured membranes presents with a high fever of \(38.9^\circ\text{ C}\) (\(102^\circ\text{ F}\)). This maternal fever, combined with ruptured membranes, is a strong clinical indicator of chorioamnionitis (intra-amniotic infection).

Evaluate the options

• Recheck the client's temperature in 4 hr: Waiting 4 hours is unsafe because an active intrapartum infection requires immediate assessment, monitoring, and intervention to prevent maternal and neonatal sepsis.
• Prepare the client for emergency cesarean section: A fever alone is not an immediate indication for an emergency cesarean delivery. Vaginal delivery is generally preferred unless there are obstetric indications (e.g., non-reassuring fetal status).
• Administer glucocorticoids intramuscularly: Glucocorticoids (like betamethasone) are used to promote fetal lung maturity in preterm labor (typically before 37 weeks). This client is at term (38 weeks), so antenatal corticosteroids are not indicated.
• Assess the odor of the amniotic fluid: Foul-smelling amniotic fluid is a classic diagnostic sign of chorioamnionitis. Assessing the odor of the fluid helps confirm the suspicion of infection, which is a key component of Obstetric Nursing assessment.

Determine the priority action

Besides notifying the provider, the nurse must gather additional assessment data to support the diagnosis of chorioamnionitis. Assessing the amniotic fluid for a foul odor is a direct, non-invasive, and immediate nursing action that helps confirm intra-amniotic infection.

Answer:

• Recheck the client's temperature in 4 hr.
• Prepare the client for emergency cesarean section.
• Administer glucocorticoids intramuscularly.
• Assess the odor of the amniotic fluid. (Correct answer)