A nurse is caring for a 34-year-old female client who is at 34 weeks of gestation in the antepartum unit.

Exhibits

What is the most appropriate action the nurse should take next?

Choice A rationale

Allowing the client to ambulate in the hallway to initiate labor is not the first appropriate action because it does not address the immediate need to monitor the client's temperature. Ambulation can be considered after ensuring there are no signs of infection or other complications.

Choice B rationale

Encouraging oral fluids and administering an antipyretic medication is not the initial priority. While hydration is important, the primary focus should be on monitoring for signs of infection, which can be indicated by changes in temperature.

Choice C rationale

Administering glucocorticoids intramuscularly is typically for promoting fetal lung maturity in cases of preterm labor, not for term pregnancies at 38 weeks. It does not address the immediate need to monitor maternal temperature after membrane rupture.

Choice D rationale

Checking the client's temperature every 2 hours is crucial to monitor for signs of infection, such as chorioamnionitis, which can occur after membrane rupture. Early detection of fever can prevent complications for both mother and baby.

A. Administer Rh immunoglobulin (Rho(D) immune globulin): This is important if the mother is Rh-negative, but there is no indication of Rh incompatibility in this scenario.

B. Perform continuous fetal heart rate monitoring: This is essential for ongoing assessment of fetal well-being but may not be the very first immediate action.

C. Prepare for emergent delivery: This would only be necessary if there were signs of fetal or maternal distress, which are not currently indicated.

D. Administer a corticosteroid to enhance fetal lung maturity: Administering corticosteroids like betamethasone or dexamethasone is crucial between 24 and 34 weeks of gestation to enhance lung maturity and reduce the risk of neonatal respiratory distress syndrome.