A nurse reviews assessment findings.

For each assessment finding, specify if the finding is consistent with a urinary tract infection or preterm labor.

Each finding may support more than one disease process.

A. Administer antihypertensive medication as prescribed - The client's blood pressure is elevated, and managing hypertension is crucial to prevent complications.

B. Initiate continuous fetal monitoring - The client is experiencing symptoms that could indicate preeclampsia, and continuous monitoring is essential to assess fetal well-being.

C. Monitor for signs of magnesium toxicity - Given the client's symptoms and lab results, monitoring for magnesium toxicity is important, especially if magnesium sulfate is being used for seizure prophylaxis.

D. Perform a vaginal exam to assess cervical status - This intervention is not a priority at this moment given the client's condition and the need to avoid unnecessary interventions that could cause stress or complications.

E. Assess for signs of placental abruption - Although the client denies vaginal bleeding, it's important to monitor for any signs of placental abruption due to her symptoms and hypertension.

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.