A woman who is 28 weeks pregnant is admitted to the high-risk OB unit with preterm premature rupture of the membranes. Four hours after admission, the nurse notes the following:
temperature: 38.5 °C (101.5 °F), maternal pulse: 122 beats/minute, and white blood cell count: 23,000 mm3. Which action by the nurse takes priority?
A.
Document the findings and notify the health-care provider.
B.
Facilitate fern testing or Nitrazine testing on vaginal fluid.
C.
Prepare to administer a prn dose of acetaminophen (Tylenol).
D.
Reassure the woman that these are expected findings.
ANS: A
Delivery for a woman with premature rupture of membranes should be accomplished immediately for signs of maternal infection, advanced labor, vaginal bleeding, or nonreassuring fetal signs. This patient's vital signs and WBC indicate infection. The nurse should document the findings and notify the health-care provider so that arrangements can proceed. Fern testing or Nitrazine testing is done to help diagnose rupture of the membranes and is not needed at this time. Giving acetaminophen at this time is not a priority and may be contraindicated if the woman needs to be placed on NPO status.
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