A nurse is assessing a pregnant client at 28 weeks gestation in the outpatient clinic who presents with fever, abdominal tenderness, and foul-smelling amniotic fluid. Her membranes ruptured 18 hours ago. Which assessment finding would be most indicative of chorioamnionitis?
A 28-year-old gravida 2, para 1 client at 36 weeks gestation presents to the labor and delivery unit with complaints of fever and abdominal pain. Her membranes ruptured 18 hours ago.
1Maternal temperature of 101.2°F (38.4°C) with maternal tachycardia of 110 bpm✓ 정답
2Decreased fetal movement with bradycardia of 100 bpm
3Blood pressure of 150/90 mmHg with proteinuria
4Vaginal bleeding with uterine contractions every 3 minutes
해설
Maternal fever with tachycardia is the most classic indicator of chorioamnionitis, reflecting systemic inflammatory response. Other findings (fetal bradycardia, hypertension/proteinuria, vaginal bleeding/contractions) are less specific or indicate other conditions like fetal distress or preeclampsia.
Core Nursing ExplanationKey Concept Analysis: This question assesses the identification of Chorioamnionitis, an infection of the fetal membranes (chorion and amnion) and amniotic fluid. It is a serious intrapartum complication often associated with prolonged rupture of membranes (PROM). The pathophysiology involves ascending bacteria from the vagina crossing the cervical barrier after membrane rupture, leading to inflammation and infection within the uterine cavity. This triggers a maternal systemic inflammatory response.
Answer Rationale: Key Point! The most classic and direct indicators of chorioamnionitis are maternal signs of systemic infection. A maternal temperature of 101.2°F (38.4°C) (normal is 98.6°F or 37°C) accompanied by maternal tachycardia (heart rate >100 bpm) are the hallmark assessment findings. Other common signs include uterine tenderness and foul-smelling amniotic fluid (already noted in the scenario). These maternal vital sign changes are the body's direct response to the infection.
Distractor Analysis:
Watch out for confusion! Option ②: Decreased fetal movement and fetal bradycardia (100 bpm; normal fetal heart rate is 110-160 bpm) are signs of fetal distress. While chorioamnionitis can *lead* to fetal distress due to fetal infection (neonatal sepsis) or maternal fever, these are secondary, fetal manifestations, not the primary indicator of the maternal infection itself.
Option ③: A blood pressure of 150/90 mmHg with proteinuria are diagnostic criteria for Preeclampsia, a hypertensive disorder of pregnancy. This is a completely different condition.
Option ④: Vaginal bleeding with regular contractions describes a patient in active labor with a potential complication like placental abruption. While infection can sometimes stimulate labor, these are not the defining signs of chorioamnionitis.
Related Concepts: Chorioamnionitis requires prompt antibiotic administration and often expedited delivery of the fetus. Prolonged rupture of membranes (PROM >18 hours) is a major risk factor. Nursing care focuses on monitoring maternal and fetal status, administering antibiotics, providing comfort measures for fever, and preparing for possible cesarean delivery if fetal distress occurs.
Concept Summary
Rupture of membranes >18 hours before onset of labor. Increases risk of ascending infection (chorioamnionitis).
Fetal Distress
Signs: Fetal bradycardia, tachycardia, late decelerations, decreased variability, decreased movement. Can be a consequence of maternal infection.
Preeclampsia
Hypertensive disorder. Signs: Hypertension (≥140/90), proteinuria, may have edema, headache, visual changes.
Side-by-Side Comparison!
Condition
Primary Maternal Signs
Primary Fetal Signs
Key Differentiator
Chorioamnionitis
Fever, Tachycardia, Uterine Tenderness
May develop bradycardia/tachycardia (secondary)
Evidence of systemic maternal infection
Fetal Distress
Often none, or maternal concern
Bradycardia, Late Decelerations, Loss of Variability
Abnormal fetal heart rate pattern
Preeclampsia
Hypertension, Proteinuria
May have IUGR (Intrauterine Growth Restriction)
Hypertension with end-organ involvement
Anatomy, Physiology & Pharmacology Points
Pathophysiology: Bacteria (often Group B Streptococcus, E. coli) ascend from vagina → cross cervix after membrane rupture → infect chorion/amnion → inflammatory cytokines released (IL-6, TNF-α) → cause maternal fever, tachycardia, and can trigger preterm labor.
Pharmacology: Broad-spectrum IV antibiotics (e.g., ampicillin + gentamicin) are started immediately. Delivery is the definitive treatment to remove the source of infection.
Memory Tips
Think "Maternal SIRS": Chorioamnionitis presents like Systemic Inflammatory Response Syndrome (SIRS) in a pregnant person: Fever + Tachycardia.
High-Frequency NCLEX Topics
NCLEX frequently tests the nurse's ability to distinguish between major obstetric emergencies. Chorioamnionitis, preeclampsia, placental abruption, and fetal distress are all high-yield. The key is to identify the cluster of defining symptoms for each condition. Remember: Fever + PROM = think infection first.
Watch Out for Question Variations!
Instead of "most indicative finding," the question could ask: "Which finding requires immediate notification of the provider?" (Answer is the same: maternal fever/tachycardia).
It could shift to nursing interventions: "The nurse should anticipate an order for..." (Answer: IV antibiotics and preparation for delivery).
It could ask about postpartum risks for the mother (endometritis, sepsis) or neonate (early-onset sepsis, pneumonia).
Nursing Clinical Practice GuideClinical Scenario: You are a nurse on Labor & Delivery. A patient at 36 weeks, G2P1, is admitted with ruptured membranes 18 hours prior. She now has a temperature of 101.5°F (38.6°C), reports abdominal pain worse with palpation, and her amniotic fluid has a foul odor. The fetal heart rate is 155 bpm with moderate variability.
Nursing Intervention Strategy:
1. Assessment & Notification: Immediately assess full vital signs (focus on temp, HR), perform a focused abdominal assessment for tenderness, and note characteristics of any fluid. This is a time-sensitive finding. Notify the provider STAT with your assessment: "Patient with PROM >18 hours now febrile with uterine tenderness and foul-smelling fluid, concerning for chorioamnionitis."
2. Monitoring: Place the patient on continuous electronic fetal monitoring (EFM). Chorioamnionitis increases the risk of fetal tachycardia initially, followed by bradycardia if distress develops. Monitor for uterine hyperstimulation or tachysystole, as infection can irritate the uterus.
3. Comfort & Safety: Administer antipyretics (e.g., acetaminophen) as ordered to reduce fever, which also benefits the fetus. Provide cool compresses, encourage fluid intake if allowed, and ensure bed rest.
4. Preparation for Delivery: Anticipate orders for IV antibiotics and labs (CBC, blood cultures). Understand that delivery (often via induction or cesarean) will be expedited. Prepare the patient and family for the likelihood of a NICU (Neonatal Intensive Care Unit) evaluation for the newborn due to the risk of sepsis.
Patient Safety and Precautions:
Do NOT perform a digital cervical exam unless absolutely necessary and ordered, as it can introduce more bacteria and worsen the infection.
Monitor for signs of maternal sepsis: worsening tachycardia, hypotension, tachypnea, altered mental status.
After delivery, monitor both mother for postpartum endometritis (fever, uterine pain, foul lochia) and newborn for early-onset sepsis (lethargy, respiratory distress, temperature instability).
Nursing Procedure & Medication FlowAntibiotic Administration for Chorioamnionitis:
1. Order Verification: Typical order: Ampicillin 2g IV every 6 hours + Gentamicin 5 mg/kg IV daily (dose adjusted for renal function).
2. Administration: Administer the first dose immediately. Time is critical. Use an IV pump. For gentamicin, infuse over 30-60 minutes.
3. Monitoring: Monitor for allergic reactions. Gentamicin is nephrotoxic and ototoxic; monitor intake/output and report hearing/balance complaints (though less common with short-term use).
4. Patient Education: Explain the purpose of the antibiotics is to treat a serious infection to protect both her and the baby.
A Word from Your Senior Nurse
"In obstetrics, a fever in the context of ruptured membranes is a red flag that should make your nursing spidey-senses tingle. You are the first line of defense in recognizing chorioamnionitis. Your rapid assessment and communication can trigger the cascade of interventions that protect two lives. Never dismiss maternal fever in labor as 'just being warm.' Always connect it to the timeline of rupture and other symptoms. This kind of critical thinking, linking risk factors (PROM) to new symptoms (fever), is exactly what NCLEX tests and what makes an excellent nurse."
Chorioamnionitis — Infection of the fetal membranes (chorion and amnion) and amniotic fluid, typically ascending from the vagina. Characterized by maternal fever, tachycardia, uterine tenderness, and foul-smelling amniotic fluid.
Prolonged Rupture of Membranes — Rupture of the amniotic sac more than 18 hours before the onset of labor. A major risk factor for ascending intra-amniotic infection (chorioamnionitis) and neonatal sepsis.
Electronic Fetal Monitoring — The use of an electronic device to continuously monitor and record the fetal heart rate and uterine contractions. Essential for assessing fetal well-being, especially in high-risk situations like chorioamnionitis.
Preeclampsia — A hypertensive disorder of pregnancy occurring after 20 weeks gestation, characterized by new-onset hypertension (≥140/90 mmHg) and proteinuria. A different condition often confused with infectious processes.
Fetal Bradycardia — A sustained fetal heart rate baseline below 110 beats per minute. A sign of potential fetal distress, which can be a consequence of conditions like chorioamnionitis, umbilical cord compression, or placental insufficiency.