A nurse is assessing a laboring client at 38 weeks gestation. Which assessment finding would be the most concerning indicator of chorioamnionitis?
1Contractions occurring every 2-3 minutes lasting 60-90 seconds
2Maternal temperature of 101.2°F (38.4°C) with fetal tachycardia of 170 bpm✓ 정답
3Amniotic fluid with light meconium staining
4Cervical dilation progressing from 6 cm to 7 cm in 2 hours
해설
Maternal fever with fetal tachycardia is the most concerning sign of chorioamnionitis, especially with prolonged rupture of membranes. Other options are normal labor findings or less specific indicators.
Core Nursing ExplanationKey Concept Analysis: This question assesses your ability to identify the most critical sign of Chorioamnionitis, an infection of the fetal membranes (chorion and amnion) and amniotic fluid. It is a serious obstetric emergency that can lead to sepsis in both the mother and fetus. The pathophysiology involves bacteria ascending from the vagina into the uterus, often after prolonged rupture of membranes (PROM). The body's inflammatory response to the infection causes systemic signs.
Answer Rationale: Key Point! The combination of maternal fever and fetal tachycardia is the hallmark and most concerning sign. Maternal fever (≥100.4°F or 38.0°C) indicates a systemic infection. Fetal tachycardia (baseline fetal heart rate > 160 bpm for ≥10 minutes) is a primary sign of fetal stress and possible infection, as the fetus increases its heart rate in response to hypoxia and inflammation. This combination directly signals a threat to two patients simultaneously.
Distractor Analysis:
Watch out for confusion! Option ① describes a normal, active labor pattern. Contractions every 2-3 minutes lasting 60-90 seconds are expected and efficient for cervical change.
Option ③: Light meconium staining can be a sign of fetal maturity or a response to transient stress, but it is not diagnostic of infection. Thick, particulate ("pea soup") meconium is more concerning, but fever is a more direct indicator of chorioamnionitis.
Option ④: Cervical dilation from 6 cm to 7 cm in 2 hours is within the normal range for the active phase of labor, especially for a nulliparous client. It does not indicate a problem.
Related Concepts: Chorioamnionitis is often associated with prolonged rupture of membranes (>18 hours). Other clinical signs include maternal tachycardia (>100 bpm), uterine tenderness, foul-smelling or purulent amniotic fluid, and maternal leukocytosis. Immediate intervention (broad-spectrum IV antibiotics and often expedited delivery) is required to prevent maternal and neonatal sepsis.
Concept Summary
Term
Description
Clinical Significance
Chorioamnionitis
Infection of the amniotic sac and fluid.
Obstetric emergency requiring antibiotics and delivery.
Maternal Fever (≥100.4°F/38.0°C)
Core diagnostic criterion.
Indicates systemic inflammatory response.
Fetal Tachycardia (>160 bpm)
Baseline fetal heart rate elevation.
Primary sign of fetal stress/infection.
Prolonged Rupture of Membranes (PROM)
Rupture >18 hours before delivery.
Major risk factor for ascending infection.
Side-by-Side Comparison!
Assessment Finding
Typical in Normal Labor
Concerning for Chorioamnionitis
Maternal Vital Signs
HR may increase slightly with pain/effort. Temp normal.
Key Point! Sustained tachycardia (>160 bpm). May also see loss of variability, decelerations.
Amniotic Fluid
Clear or with light meconium (may be normal).
Foul-smelling, purulent.
Uterus
Firm with contractions, relaxes between.
Tender between contractions.
Anatomy, Physiology & Pharmacology PointsPathophysiology: Bacteria (often Group B Streptococcus, E. coli) ascend through the cervix after membrane rupture, infecting the chorion, amnion, and amniotic fluid. The inflammatory response releases cytokines and prostaglandins, which can cause fever, trigger labor, and lead to fetal inflammatory response syndrome (FIRS).
Pharmacology: First-line treatment is IV antibiotics like ampicillin plus gentamicin. Clindamycin is added for anaerobic coverage if cesarean delivery is performed. Antibiotics are given to treat maternal infection and reduce neonatal morbidity.
Memory Tips
Mnemonic: "Fever & Fetal Tachycardia = FIRE" – These two findings together signal an internal FIRE (infection) that requires immediate intervention.
Association: Think of the "Two T's" – Mother's Temperature and Baby's Tachycardia. When both are up, it's time to call the provider.
High-Frequency NCLEX Topics
Chorioamnionitis is a classic NCLEX topic testing priority-setting and infection recognition. You must know that maternal fever + fetal tachycardia is the red flag combination. NCLEX will also test nursing actions: notify provider, administer prescribed IV antibiotics, monitor maternal and fetal vital signs closely, and prepare for possible expedited delivery.
Watch Out for Question Variations!
* From Symptom to Action: "The nurse notes a temp of 101.5°F and fetal HR 170 bpm in a laboring client with ROM 24 hours ago. What is the priority nursing action?" (Answer: Notify the healthcare provider immediately).
* Postpartum Focus: "A client delivered 12 hours ago and has a temp of 102°F, uterine tenderness, and foul-smelling lochia. The nurse suspects..." (Answer: Endometritis, a postpartum infection often linked to chorioamnionitis).
* Medication Focus: "Which IV antibiotic regimen would the nurse anticipate administering for chorioamnionitis?" (Answer: Ampicillin + Gentamicin).
Nursing Clinical Practice GuideClinical Scenario: You are caring for G2P1 client, Maria, at 39 weeks gestation who has been in labor for 10 hours with ruptured membranes for 22 hours. During your assessment, you find her shivering. Her vital signs are: T 101.8°F (38.8°C), P 112 bpm, R 22/min, BP 118/74. On the electronic fetal monitor (EFM), the fetal heart rate baseline is 168-172 bpm with minimal variability.
Nursing Intervention Strategy:
1Assessment & NotificationImmediately recognize this as a potential chorioamnionitis emergency. Document findings thoroughly and notify the obstetric provider/charge nurse STAT.
2Implement OrdersAnticipate and prepare for:
* IV antibiotic administration (e.g., ampicillin 2g IV).
* Blood cultures and complete blood count (CBC) drawn.
* Increased frequency of maternal vital signs (every 30-60 minutes) and continuous EFM.
* Plans for expedited delivery (may involve augmentation of labor or preparation for cesarean section).
3Supportive CareProvide cooling measures (cool cloth, light bedding), encourage oral fluids if allowed, and administer antipyretics (e.g., acetaminophen) as ordered to reduce fever and maternal discomfort.
4Patient EducationExplain the signs of infection simply and calmly to Maria and her partner. Reassure them that the team is acting quickly to protect her and the baby.
Patient Safety and Precautions:
* Key Point! Do not delay antibiotic administration. Time to first dose is critical for outcomes.
* Monitor for signs of maternal sepsis: hypotension, tachypnea, altered mental status, worsening tachycardia.
* Monitor for worsening fetal status: prolonged decelerations, late decelerations, bradycardia.
Nursing Procedure & Medication FlowAdministering IV Antibiotics for Chorioamnionitis:
1VerifyConfirm provider order (drug, dose, route, frequency). Check for penicillin allergy (ampicillin is a penicillin).
2PrepareObtain medication from Pyxis/med room. Perform the Five Rights of medication administration.
3AdministerUse a large-bore IV line. For ampicillin, it is often given IV push over 3-5 minutes or as an IV piggyback (IVPB) infusion. Flush line before and after with normal saline.
4MonitorObserve for allergic reaction (rash, itching, wheezing) during and for 30 minutes after administration. Monitor for effectiveness (reduction in fever, improvement in fetal heart rate pattern).
A Word from Your Senior Nurse
"Labor and delivery nursing is about vigilant surveillance. A fever in labor isn't just 'mom being warm'—it's a potential siren for infection affecting two lives. Your assessment is the first line of defense. When you see that elevated temperature on the monitor, your next immediate action should be to check the fetal heart rate strip. Putting those two pieces of data together is what makes you a safe and effective nurse. On the NCLEX, they are testing your clinical judgment: can you pick out the abnormal finding from a list of normal labor events? Master this, and you'll be ready for both the exam and the real-world urgency of the delivery room."
Chorioamnionitis — Infection of the fetal membranes (chorion and amnion) and amniotic fluid, characterized by maternal fever, fetal tachycardia, and often uterine tenderness.
Fetal Tachycardia — A baseline fetal heart rate greater than 160 beats per minute sustained for 10 minutes or more, often a sign of fetal stress, hypoxia, or infection.
Prolonged Rupture of Membranes — Rupture of the amniotic sac more than 18 hours before the onset of labor, a significant risk factor for ascending intra-amniotic infection.
Electronic Fetal Monitoring — The use of equipment to continuously or intermittently monitor the fetal heart rate and uterine contractions during labor, essential for detecting fetal distress.
Sepsis — A life-threatening organ dysfunction caused by a dysregulated host response to infection; a potential complication of untreated chorioamnionitis for both mother and neonate.