Question

A woman is being observed in the hospital because her membranes ruptured at 30 weeks gestation. While providing morning care, the nurse student notices that the draining fluid has a strong odor. The priority nursing action is to:

1. caution the woman to remain in bed until her physician visits.
2. ask the woman if she is having any more contractions than usual.
3. take the woman's temperature; report it and the fluid odor to the RN.
4. help to prepare the woman for an immediate cesarean delivery.

Answer 1

The priority action is to report the fluid odor and take the woman's temperature as it could indicate infection, which is a risk for both mother and fetus. Immediate cesarean delivery is not necessarily the first step without assessing for other signs of distress or maternal risks. Option 3.

Step-by-step explanation:

When a pregnant woman is observed in the hospital due to ruptured membranes at 30 weeks gestation and is noted to have amniotic fluid with a strong odor, the priority nursing action is to take the woman's temperature, report it, and the fluid odor to the RN. This takes priority because an odor to the fluid may indicate infection which can pose a risk to both the mother and the fetus. The nurse should also observe for other signs of infection and monitor the fetal heart rate. Immediate delivery via cesarean section may not be necessary unless there are other indications of fetal distress or significant maternal health risks.

It's essential for the healthcare team to carefully assess both maternal and fetal condition to determine the most appropriate course of action. The priority nursing action in this situation is to take the woman's temperature and report it along with the fluid odor to the Registered Nurse (RN). A strong odor in the draining fluid could indicate a possible infection, and it is important to monitor the woman's temperature for any signs of fever, which could also be a sign of infection.

Answer 2

The priority action is to report the fluid odor and take the woman's temperature as it could indicate infection, which is a risk for both mother and fetus. Immediate cesarean delivery is not necessarily the first step without assessing for other signs of distress or maternal risks. Option 3.

Step-by-step explanation:

When a pregnant woman is observed in the hospital due to ruptured membranes at 30 weeks gestation and is noted to have amniotic fluid with a strong odor, the priority nursing action is to take the woman's temperature, report it, and the fluid odor to the RN. This takes priority because an odor to the fluid may indicate infection which can pose a risk to both the mother and the fetus. The nurse should also observe for other signs of infection and monitor the fetal heart rate. Immediate delivery via cesarean section may not be necessary unless there are other indications of fetal distress or significant maternal health risks.

It's essential for the healthcare team to carefully assess both maternal and fetal condition to determine the most appropriate course of action. The priority nursing action in this situation is to take the woman's temperature and report it along with the fluid odor to the Registered Nurse (RN). A strong odor in the draining fluid could indicate a possible infection, and it is important to monitor the woman's temperature for any signs of fever, which could also be a sign of infection.