RN Nursing · High-Risk Pregnancy — Preterm Labor · Practice question
A nurse is caring for a client who is in labor. Select 1 parameter and 1 complication to fill in each blank in the following sentence. The nurse should monitor the client’s ____ due to the risk of ____.
Medical History
Gravida 2, Para 1
34 weeks of gestation
Uncomplicated pregnancy
Previous spontaneous vaginal birth
History of migraine headaches
Nurse’s Notes
0800:
Client reports increased clear vaginal discharge for the past 12 hr. Denies cramping or contractions. Confirms fetal movement is present and unchanged.
Moderate amount of clear drainage present on the client's peri pad.
Bilateral lower extremity non-pitting edema noted. Deep tendon reflexes 2+. Client reports a migraine headache that started a few hours ago. Reports pain as 4 on a scale of 0 to 10.
External fetal monitor applied.
0900:
Fetal heart rate 132/min. Moderate variability. Spontaneous accelerations present. No decelerations observed. No contractions noted.
Vital Signs
0800:
Temperature 36,7° C (98° F)
Heart rate 88/min
Respiratory rate 18/min
Blood pressure 114/68 mm Hg
Pulse oximeter 98%
Diagnostic Results
0900:
Speculum examination by provider
Cervix closed
Clear fluid noted in vagina. Ph 7.0.
Microscopic examination of vaginal fluid sample demonstrates crystallized ferning pattern.
Preterm premature rupture of membranes confirmed.
Answer & explanation
Correct:
This client has confirmed preterm premature rupture of membranes (PPROM) at 34 weeks. Once membranes rupture, the protective barrier between the uterine environment and the outside world is lost, creating a direct pathway for ascending bacteria. The most serious and life-threatening maternal complication of PPROM is chorioamnionitis — infection of the amniotic fluid, membranes, placenta, and uterus. The primary parameter the nurse must monitor is temperature, because fever is the earliest and most reliable clinical sign of developing chorioamnionitis. Monitoring temperature allows for early detection and prompt intervention, including antibiotic therapy and possible delivery. Clotting factors and disseminated intravascular coagulation (DIC) are associated with placental abruption or septic shock, not PPROM specifically. Reflexes and magnesium levels are monitored in preeclampsia, which is not present here — blood pressure is normal and deep tendon reflexes are 2+ (normal). Fundal height is not relevant to detecting infection. Seizures are a complication of preeclampsia/eclampsia, and respiratory arrest relates to magnesium toxicity. Therefore, the nurse should monitor the client's temperature due to the risk of chorioamnionitis.
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