Signs and symptoms
Signs and symptoms ( 10 Questions)
A nurse is assessing a client who has been in labor for 14 hours and has a fever of 38.2°C (100.8°F).
The nurse notes that the amniotic fluid is foul-smelling.
Which of the following actions should the nurse take first?
administering antibiotics as prescribed is not the first action the nurse should take. The nurse should notify the provider before giving any medication, as the prescription may need to be changed based on the assessment findings.
The nurse should report the findings of a fever and foul-smelling amniotic fluid to the provider as soon as possible, as they may indicate an infection of the amniotic sac and fluid (chorioamnionitis) . Chorioamnionitis can cause serious complications for both the mother and the baby, such as sepsis, preterm birth, and neonatal pneumonia .
Therefore, notifying the provider is the priority action.
Obtaining a blood culture is not the first action the nurse should take. A blood culture may be ordered by the provider to confirm the diagnosis of chorioamnionitis and identify the causative organism , but it is not a priority over notifying the provider.
Increasing the IV fluid rate is not the first action the nurse should take. Increasing the IV fluid rate may be done to prevent dehydration and hypotension in the mother , but it is not a priority over notifying the provider.
The nurse should report the findings of a fever and foul-smelling amniotic fluid to the provider as soon as possible, as they may indicate an infection of the amniotic sac and fluid (chorioamnionitis) . Chorioamnionitis can cause serious complications for both the mother and the baby, such as sepsis, preterm birth, and neonatal pneumonia.
Therefore, notifying the provider is the priority action.