A nurse takes vital signs of a pregnant client; temperature 100.6 F, pulse 100, respirations 24. What is the most appropriate nursing action?

• A. Document the findings in the client's medical record
• B. Continue collecting subjective and objective data
• C. Recheck the vital signs in 1 hour
• D. Notify the nurse-midwife of the findings

Answer: (D)

In pregnancy, a fever is a red flag that requires prompt escalation to the obstetric care team. The temperature is mildly elevated, and the accompanying tachycardia and increased respirations suggest the body is under stress, potentially from an infectious process. Asking the nurse-midwife to assess now allows for quick determination of the cause—such as urinary tract infection, chorioamnionitis, or other infection—and timely management, which can be crucial for both mother and fetus. Delaying by documenting only, continuing data collection without involving the care provider, or waiting an hour could allow a developing infection to worsen. Elevating the concern to the nurse-midwife ensures appropriate testing, monitoring, and treatment decisions are made promptly.