Questions: Which action is most important in the nursing plan of care for a 37 weeks' gestation client whose membranes spontaneously rupture but she does not have any labor contractions? Monitoring for the presence of fever Monitoring for signs of preeclampsia Monitoring for heavy vaginal bleeding Making preparations for fetal scalp pH sampling

The answer is the first one: Monitoring for the presence of fever.

Explanation for each option:

1. Monitoring for the presence of fever: This is the most important action because the spontaneous rupture of membranes (SROM) increases the risk of infection, such as chorioamnionitis. Monitoring the client's temperature can help detect an infection early, which is crucial for the health of both the mother and the baby.

2. Monitoring for signs of preeclampsia: While important, preeclampsia is not directly related to the spontaneous rupture of membranes. Preeclampsia involves high blood pressure and other symptoms, but the immediate concern with SROM is the risk of infection.

3. Monitoring for heavy vaginal bleeding: Heavy vaginal bleeding is a serious concern, but it is not the most immediate risk associated with SROM without labor contractions. The primary concern is infection rather than bleeding.

4. Making preparations for fetal scalp pH sampling: This is not immediately necessary in the context of SROM without labor contractions. Fetal scalp pH sampling is typically used to assess fetal well-being during labor, particularly if there are concerns about fetal distress.

Summary: The most important action in the nursing plan of care for a 37 weeks' gestation client whose membranes have spontaneously ruptured but who does not have any labor contractions is monitoring for the presence of fever to detect any signs of infection early.