Growth and Development Q 44
A woman who is 32 years old and 35 weeks pregnant has had rupture of membranes for eight hours and is four (4) cm dilated. Since she is a candidate for infection, the nurse should include which of the following in the care plan?
A. Universal precautions
B. Oxytocin administration
C. Frequent temperature monitoring
D. More frequent vaginal examinations
Correct Answer: C. Frequent temperature monitoring
Temperature elevation will indicate beginning infection. This is the most important measure to help assess the client for infections since the lost mucus plug and the ruptured membranes increase the potential for ascending bacteria from the reproductive tract. This will infect the fetus, membranes, and uterine cavity.
Option A: Universal precautions are necessary for all clients but a specific assessment of the client’s temperature will give an indication the client is becoming infected.
Option B: Oxytocin may be needed to induce labor if it is not progressing, but it is not done initially. In the antepartum period, exogenous oxytocin is FDA-approved for strengthening uterine contractions with the aim of successful vaginal delivery of the fetus. It is indicated for mothers with inactive uteri that require stimulation to start labor
Option D: More frequent vaginal examinations are not recommended, as frequent vaginal exams can increase the chances of infection. VEs following rupture of membranes has been demonstrated to increase the risk of chorioamnionitis. Obstetricians are, therefore, routinely expected to weigh the need for VEs for the assessment of labor progression, against the risk of maternal discomfort and of infection with an increased number of examinations.