RN Nursing · High-Risk Pregnancy — Preterm Labor · Practice question
A nurse is caring for a client on the labor and delivery unit. A nurse is evaluating the client who is in preterm labor. Click to highlight the findings below that would indicate that the client has a potential problem. To deselect a finding. click on the finding again.
Nurses' Notes
Vital Signs
0830:
oral temperature 36.9°C (98.4°F)
Heart rate 89/min
Respiratory rate 16/min
Blood pressure 110/60 mm Hg
SaO2 97% on room air
0930:
Oral temperature 37.6°C (99.7°F)
Heart rate 90/min
Respiratory rate 20/min
Blood pressure 120/68 mm Hg
SaO2 98% on room air
1030:
Oral temperature 37.9°C (100.2°F)
Heart rate 94/min
Respiratory rate 20/min
Blood pressure 110/60 mm Hg
SaO2 97% on room air
1130:
Oral temperature 38.3°C (101°F)
Heart rate 98/min
Respiratory rate 18/min
Blood pressure 112/59 mm Hg
SaO2 on room air
0830:
Client is at 30 weeks of gestation, Gravida 2 Para 1 with no prenatal care. Presents with reports of low back pain and abdominal cramping for 2 days. History of cesarean birth x 1 for breech presentation. Client reports smoking a half a pack of cigarettes per day. BMI is greater than 30. The client is grimacing. External electronic fetal monitor applied, and fetal heart rate is 148/min. Positive fetal movement noted. Abdomen is soft and nontender to palpation. Denies leakage of amniotic fluid. Fundal height is 28 cm (1 1 in). Sterile vaginal examination (SVE) 2 cm, 80%, -1 station. Mucous vaginal discharge and small amount of bleeding observed.
0845:
Uterine contractions occurring every 2 to 3 min, moderate in strength.
0930:
Received client from the provider's office. Admitted to the labor and delivery unit. SVE 2 cm, 80%, -1 station
External electronic fetal monitor applied. Fetal heart rate 160/min
0945:
Uterine contractions occurring every 2 to 3 min, moderate in strength.
Diagnostic Results
0900:
Hgb 11 g/dL (greater than 11 g/dL)
Hct 32% (greater than 33%)
WBC count 20,000/mm3 (5,000 to 10.000/mm3)
Maternal Blood Type O negative
1200:
Hgb 12 g/dL (11 to 16 g/dL)
Hct 34% (33% to 47%)
WBC count 22,000/mm3 (5,000 to 10,000/mm3)
Provider’s Prescription
1000:
Betamethasone 12 mg IM now, repeat in 24 hr
Terbutaline 0.25 mg subcutaneous now
Magnesium sulfate 4 g IV bolus over 30 min, followed by maintenance dose at 2 g/hr
Insert 16-French indwelling urinary catheter.
Collect urine and vaginal cultures.
Nurse’s Notes
0830:
Client is at 30 weeks of gestation, Gravida 2 Para 1 with no prenatal care. Presents with reports of low back pain and abdominal cramping for 2 days. History of cesarean birth x 1 for breech presentation. Client reports smoking a half a pack of cigarettes per day. BMI is greater than 30. The client is grimacing. External electronic fetal monitor applied, and fetal heart rate is 148/min. Positive fetal movement noted. Abdomen is soft and nontender to palpation. Denies leakage of amniotic fluid. Fundal height is 28 cm (11 in). Sterile vaginal examination (SVE) 2 cm, 80%, -1 station. Mucous vaginal discharge and small amount of bleeding observed.
0845:
Uterine contractions occurring every 2 to 3 min, moderate in strength.
0930:
Received client from the provider's office. Admitted to the labor and delivery unit. SVE 2 cm, 80%, -1 station
External electronic fetal monitor applied. Fetal heart rate 160/min
0945:
Uterine contractions occurring every 2 to 3 min, moderate in strength.
1030:
An 18-gauge IV catheter is inserted into the left hand, and the client is given an IV bolus of lactated Ringer's. Magnesium sulfate 4 g IV bolus started. Fetal heart rate 160/min. Pain rating of 8 on a scale of 0 to 10. Client is grimacing and crying. Client reports having lower abdominal and back pain. The 16-French indwelling urinary catheter is draining a small amount of cloudy urine.
1130:
Client states, "l think my water broke. The pad under me is saturated." Clear fluid noted on pad. Nitrazine positive. Uterine contractions every 3 min, moderate to palpation, Fetal heart rate is 140/min.
Diagnostic Results
0900:
Hgb 11 g/dL (greater than 11 g/dL)
Hct 32% (greater than 33%)
WBC count 20,000/mm3 (5,000 to 10,000/mm3)
Maternal Blood Type O negative
1200:
Hgb 12 g/dL (greater than 11 g/dL)
Hct 34% (greater than 33%)
WBC count 22,000/mrn3 (5,000 to 10,000/mm3)
Provider's Prescription
1000:
Betamethasone 12 mg 1M now, repeat in 24 hr
Terbutaline 0.25 mg subcutaneous now
Magnesium sulfate 4 g IV bolus over 30 min, followed by maintenance dose at 2 g/hr
Insert 16-French indwelling urinary catheter.
Collect urine and vaginal cultures.
Provider Prescriptions
1000:
Betamethasone 12 mg 1M now, repeat in 24 hr
Terbutaline 0.25 mg subcutaneous now
Magnesium sulfate 4 g IV bolus over 30 min, followed by maintenance dose at 2 g/hr
Insert 16-French indwelling urinary catheter.
Collect urine and vaginal cultures.
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Vital Signs 1130: Oral temperature 38.3°C (101°F) Heart rate 98/min Respiratory rate 18/min Blood pressure 112/59 mm Hg SaO2 on room air Nurses' Notes 1130: Client states, "l think my water broke. The pad under me is saturated." Clear fluid noted on pad. Nitrazine positive. Uterine contractions every 3 min. moderate to palpation. Fetal heart rate is 140/min. Diagnostic Results 1200: Hgb 12 g/dL (11 to 16 g/dL) Hct (33% to 47%) WBC count 22,000/mm3 (5,000 to 10,000/mm3)
Answer & explanation
Correct:
The findings that indicate a potential problem for this client in preterm labor are the rising temperature trend, the elevated and rising WBC count, the cloudy urine from the catheter, the ruptured membranes at 1130 (Nitrazine positive, saturated pad), and the fetal heart rate of 160/min which is at the upper limit of normal and trending upward from 148 to 160. The oral temperature has risen progressively from 36.9°C at 0830 to 38.3°C (101°F) at 1130, crossing the fever threshold and suggesting chorioamnionitis or another infection. The WBC count rose from 20,000 to 22,000/mm³, both significantly above the normal upper limit of 10,000/mm³, indicating an escalating infectious or inflammatory process. The cloudy urine noted in the 1030 nurse's note suggests urinary tract infection. The 1130 note documents rupture of membranes, confirmed by Nitrazine positive result, which changes the clinical picture significantly — premature rupture of membranes at 30 weeks increases infection risk and may accelerate delivery. The SaO2 field at 1130 is incomplete (no value recorded), which is itself a documentation concern. These findings collectively point toward possible chorioamnionitis complicating preterm labor, requiring urgent provider notification and intervention.
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