During Jessica's management for preterm labor with cervical insufficiency, which nursing intervention is most critical in preventing further progression of labor?

B) Administering magnesium sulfate as prescribed to provide neuroprotection.

A) Encouraging Jessica to ambulate frequently to maintain circulation.

B) Administering magnesium sulfate as prescribed to provide neuroprotection.

C) Performing frequent vaginal examinations to assess cervical changes.

D) Implementing strict bed rest to minimize uterine contractions.

Given Jessica's clinical presentation and treatment plan, which nursing intervention is most critical to prioritize at this time to manage her risk of preterm labor?

C) Monitoring for signs of magnesium sulfate toxicity.

A) Administering a corticosteroid to enhance fetal lung maturity.

B) Encouraging strict bed rest to prevent further cervical changes.

C) Monitoring for signs of magnesium sulfate toxicity.

D) Educating Jessica on recognizing signs of labor progression.

A nurse is caring for a pregnant patient, Jessica, who has been diagnosed with premature rupture of membranes (PROM) at 32 weeks of gestation. Which nursing intervention is the highest priority to prevent complications associated with PROM?

B) Administer prophylactic antibiotics to prevent infection.

A) Initiate corticosteroid therapy to accelerate fetal lung maturity.

B) Administer prophylactic antibiotics to prevent infection.

C) Monitor maternal vital signs and fetal heart rate closely.

D) Prepare for immediate delivery to prevent preterm labor complications.

Jessica is experiencing premature rupture of membranes (PROM) at 32 weeks of gestation. Which nursing intervention is most critical to prioritize in her care plan to prevent further complications?

C) Monitor maternal temperature every 4 hours to detect signs of infection.

A) Encourage frequent ambulation to promote fetal descent.

B) Administer corticosteroids as prescribed to enhance fetal lung maturity.

C) Monitor maternal temperature every 4 hours to detect signs of infection.

D) Perform a biophysical profile to assess fetal well-being.

A nurse is reviewing the care plan for Jessica, who is experiencing frequent contractions and has signs of a possible subclinical infection. Which action should the nurse prioritize to address both the risk of infection and the potential for preterm labor?

D) Administer a second course of betamethasone to enhance fetal lung maturity.

A) Administer a tocolytic agent to suppress contractions.

B) Monitor maternal vital signs and fetal heart rate closely.

C) Prepare for immediate delivery to minimize infection risk.

D) Administer a second course of betamethasone to enhance fetal lung maturity.

Jessica is a patient at 34 weeks gestation experiencing frequent contractions, cervical dilation, and increased pelvic pressure. Her white blood cell count and C-reactive protein levels are elevated. What is the priority nursing action at this time?

C) Continue fetal monitoring and assess for signs of preterm labor progression.

A) Administer the second course of betamethasone as ordered.

B) Prepare for immediate delivery and notify the neonatal team.

C) Continue fetal monitoring and assess for signs of preterm labor progression.

D) Initiate broad-spectrum antibiotics to address suspected infection.

A pregnant patient at 30 weeks' gestation, experiencing preterm labor, is being transferred to a tertiary care facility. Which intervention should the nurse prioritize to prepare Jessica for safe transfer?

D) Confirm administration of betamethasone for fetal lung maturity

A) Administer a tocolytic agent to suppress contractions

B) Provide patient education about preterm labor signs

C) Ensure continuous fetal monitoring during transport

D) Confirm administration of betamethasone for fetal lung maturity

A nurse is caring for a patient, Jessica, who is experiencing preterm labor with signs of potential infection. Which of the following nursing interventions should the nurse prioritize to address the current clinical situation?

C) Initiate antibiotic therapy as prescribed to address the potential infection.

A) Administer another dose of tocolytics to further suppress contractions.

B) Prepare for immediate delivery due to the risk of fetal distress.

C) Initiate antibiotic therapy as prescribed to address the potential infection.

D) Focus on pain management to alleviate the patient's discomfort.

A nurse is caring for Jessica, who is in preterm labor at a tertiary care facility. Given her current condition and management plan, what is the priority nursing intervention to optimize fetal outcomes?

A) Administer the second dose of betamethasone as scheduled.

B) Monitor Jessica's pain levels and administer IV acetaminophen as prescribed.

C) Prepare for potential neonatal resuscitation in anticipation of preterm delivery.

D) Regularly assess Jessica's vital signs and uterine contraction patterns.

A nurse is caring for a patient, Jessica, who is experiencing preterm labor with a suspected underlying infection. Which nursing intervention should be prioritized to ensure the safety of both the mother and the fetus?

B) Initiating frequent fetal heart rate monitoring to assess for signs of fetal distress.

A) Administering the second course of betamethasone as prescribed to enhance fetal lung maturity.

B) Initiating frequent fetal heart rate monitoring to assess for signs of fetal distress.

C) Preparing for potential delivery by ensuring neonatal resuscitation equipment is ready.

D) Administering IV acetaminophen to manage Jessica's discomfort.

Nursing Case Study: Preterm Labor with Shortened Cervix and Cerclage Patient Profile Name: Jessica Martinez Age: 28 years Gravida/Para: G2P (Second pregnancy, no live births) Gestational Age: 27 weeks and 4 days Admitting Diagnosis: Threatened preterm labor with cervical shortening Allergies: None known • Prenatal History: Previous spontaneous abortion at 19 weeks due to cervical incompetence Chief Complaint "I've been having cramping and pressure in my lower abdomen for the past few hours." History of Present Illness Jessica arrived to the labor and delivery triage unit reporting intermittent cramping, backache, and pelvic pressure for the past 6 hours. She denies vaginal bleeding or leakage of fluid. Fetal movement is present. She has been followed closely by her obstetrician for a known short cervix (1.8 cm at 24 weeks). A prophylactic cerclage was placed at 16 weeks gestation due to her prior history. She has been compliant with weekly 17-hydroxyprogesterone injections since 16 weeks. Physical Assessment Assessment Findings General Appearance Alert, anxious, appears mildly uncomfortable Vital Signs BP 118/72 mmHg. HR 04 bpm, RR 20/min, Temp 98,6°F, SpO, 99% Abdomen Gravid, soft, mild uterine irritability on palpation Fetal Heart Rate Baseline 140 bpm, moderate variability, no decelerations Vaginal Exam Cerclage intact, cervix I cm dilated, 50% effaced, membranes intact Contractions (TOCO) Irregular contractions every 7-10 minutes Fetal Fibronectin (fFN) Negative Suggests low risk of delivery in next 7-14 days CBC WBC 10.2 x10¾/uL, Hgb 12.1 g/dL, Het 36%, Plt 220k Within normal limits Urinalysis Negative for infection R/O UTI as cause of contractions Transvaginal Ultrasound Cervical length 1.5 cm, cerclage visualized, no funneling Shortened cervix confirmed NST (Non-Stress Test) Reactive Fetal well-being reassuring Findings Vital Signs BP 118/72 mmHg. HR 04 bpm, RR 20/min, Temp 98,6°F, SpO, 99% Abdomen Gravid, soft, mild uterine irritability on palpation Fetal Heart Rate Baseline 140 bpm, moderate variability, no decelerations Vaginal Exam Cerclage intact, cervix I cm dilated, 50% effaced, membranes intact Contractions (TOCO) Irregular contractions every 7-10 minutes Hospital Course Jessica was admitted for observation and management of preterm labor. She was placed on bed rest with bathroom privileges, started on IV hydration, and continuous fetal monitoring. Medications Administered: Outcome: After 48 hours of monitoring, contractions subsided and the patient remained stable. She was discharged home with strict activity modification and follow-up in 1 week. Discharge Medications & Instructions Medications: Medication Dose/Route Purpose Terbutaline 0.25 mg SQ xl dose Tocolytic - relaxes uterine smooth muscle Magnesium sulfate Loading dose 4 g IV over 20 min, then 2 g/hr Neuroprotection and tocolysis Betamethasone 12 mg IM, 2 doses 24 hours apart Accelerates fetal lung maturity 17-hydroxyprogesterone caproate Weekly IM Prevents preterm labor recurrence Hydration and uterine relaxation IV fluids (LR) 100 mL/hr support Acetaminophen 650 mg PO q6h PRN Mild pain or fever relief Continue 17-hydroxyprogesterone eapronte injections weekly Prenatal vitamins daily : Magnesium oxide 400 mg PO daily, Acetaminophen 650 mg PO q6h PRN for mild pain Instructions: Modified bed rest (avoid heavy lifing, standing for long periods, or intercoursel Monitor for signs of pretern labor (pelvic pressure, contractions, vaginal bleeding, leaking fluid) Maintain adequate hydration (8-10 glasses of water daily) Keep all prenatal and ultrasound appointments Call the provider or go to Labor & Delivery if • Contractions become regular or painful Leakage of fluid or bleeding occurs Decreased fetal movement is noted Nursing Care Plan Nursing Diagnosis Risk for Preterm Labor related to cervical insufficiency and uterine irritability Anxiety related to threat of preterm delivery Goals/Expected Outcomes Nursing Interventions Evaluation - Monitor uterine activity and fetal heart rate - Administer prescribed Contractions resolved; Maintain pregnancy until at tocolytics and patient stable; understands least 34 weeks gestation corticosteroids discharge instructions Maintain hydration Provide education about warning signs Provide emotional support Explain all Patient verbalizes decreased procedures and anxiety and understanding medications Patient reports feeling reassured and prepared for discharge of care plan - Encourage questions and family involvement Patient Education Summary • • Importance of adhering to progesterone therapy and follow-up care Understanding purpose of cerclage and when to contact provider Early recognition of preterm labor symptoms Importance of rest and stress reduction Extended Student Research & Discussion Questions Pathophysiology & Assessment 1. 2. 3. 4. 8. 9. Describe the normal physiological changes of the cervix during pregnancy. How does cervical shortening differ from cervical effacement? What are the possible etiologies of a shortened cervix in pregnancy? Explain how infection or inflammation may contribute to preterm labor. What role does uterine irritability play in the development of preterm contractions? What are early warning signs of preterm labor that a nurse should assess for? Discuss how transvaginal ultrasound is used to monitor cervical length and funneling. Identify key differences between true labor and false labor (Braxton Hicks) contractions. What factors increase the risk for preterm labor and birth? Medications & Interventions Compare tocolytic medications (Magnesium sulfate, Terbutaline, Nifedipine, Indomethacin) - include mechanism, side effects, and contraindications. Why is hydration an important non-pharmacologic intervention for uterine irritability? What monitoring parameters must be in place when administering Magnesium sulfate? What are the signs of Magnesium toxicity, and what is the antidote? Discuss why antibiotics might be prescribed in cases of premature rupture of membranes (PROM). What is the role of progesterone therapy in preventing preterm labor? What nursing assessments are required during and after cerclage placement? When should a cerclage be removed, and what nursing considerations apply at that time? How would nursing management change if the patient's membranes ruptured? Nursing Process & Documentation 19. Write an SBAR handoff report summarizing the patient's situation, background, assessment, and recommendations. - Nursing Case Study

Pathophysiology

• Primary mechanism: Cervical Insufficiency

• The cervix fails to maintain its integrity, leading to premature dilation and effacement. This is often due to structural weakness or scar tissue, and in Jessica's case, is indicated by her previous spontaneous abortion and current cervical shortening.

• Secondary mechanism: Uterine Irritability

• Uterine irritability involves irregular contractions that may not progress labor but can contribute to cervical changes, potentially triggering preterm labor. This irritability can be exacerbated by dehydration or infection.

• Key complication: Preterm Labor Risk

• With a shortened cervix and uterine irritability, there is a heightened risk for preterm delivery before fetal maturity, necessitating interventions like cerclage, tocolytics, and corticosteroids to prolong pregnancy and enhance fetal outcomes.

Patient Profile

Demographics:

Jessica Martinez, 28-year-old female, homemaker

History:

• Previous spontaneous abortion at 19 weeks due to cervical incompetence

• Current medications: 17-hydroxyprogesterone caproate weekly, prenatal vitamins, magnesium oxide, acetaminophen PRN

• Allergies: None known

Current Presentation:

• Chief complaint: "I've been having cramping and pressure in my lower abdomen for the past few hours."

• Key symptoms: Intermittent cramping, backache, pelvic pressure, no vaginal bleeding or leakage of fluid, fetal movement present

• Vital signs: BP 118/72 mmHg, HR 104 bpm, RR 20/min, Temp 98.6°F, SpO2 99%

Section 1

As Jessica progressed in her hospital stay, a change in her status was observed. On the third day of her admission, she reported increased pelvic pressure and more frequent contractions, occurring every 5 minutes and lasting approximately 45 seconds. Despite initial stabilization, these changes prompted a re-evaluation of her condition. Her vital signs remained stable with a blood pressure of 116/74 mmHg, heart rate of 102 bpm, respiratory rate of 20/min, and temperature of 98.7°F. However, upon examination, her cervix was found to be 2 cm dilated and 60% effaced, suggesting progression in cervical changes.

In response to these developments, the healthcare team decided to intensify Jessica's management. An additional dose of magnesium sulfate was administered to further assist in tocolysis and neuroprotection. A repeat fetal fibronectin test was conducted, and the results returned positive, indicating a higher risk of delivery within the next two weeks. Continuous fetal monitoring was maintained, which showed a reassuring fetal heart rate pattern with moderate variability and no decelerations. To address the increased risk of preterm birth, Jessica was counseled on the possibility of escalating care, including transfer to a facility with a higher level of neonatal care, should her condition worsen.

This change in Jessica's status highlighted the complexity of managing preterm labor in the context of cervical insufficiency and necessitated a multidisciplinary approach. The healthcare team emphasized the importance of Jessica's adherence to activity restrictions and hydration, while also preparing her for potential scenarios, including the possibility of preterm delivery. Through constant monitoring and timely interventions, the goal remained to prolong her pregnancy to allow for further fetal development, while also preparing for any emergent situations.

Section 2

New Complications

On the fourth day of Jessica's hospital stay, further developments indicated potential complications in her clinical course. Despite the administration of additional magnesium sulfate and continued bed rest, Jessica began experiencing increased discomfort and reported a sudden gush of fluid, raising concerns about premature rupture of membranes (PROM). Her vital signs remained stable with a blood pressure of 118/76 mmHg, heart rate of 100 bpm, respiratory rate of 22/min, and temperature of 98.8°F. However, the physical assessment revealed new findings: the amniotic fluid was pooling during the speculum exam, and a nitrazine test confirmed the presence of amniotic fluid. These findings were consistent with PROM.

In response to this complication, the healthcare team initiated a course of antibiotics to reduce the risk of infection, given the increased vulnerability associated with PROM. Continuous fetal monitoring was maintained, showing a stable fetal heart rate pattern with moderate variability, but the risk of infection and preterm delivery loomed larger. A complete blood count was ordered to monitor for signs of infection, with special attention to white blood cell counts. Jessica's anxiety understandably increased, prompting the healthcare team to provide emotional support and detailed explanations about the current situation and the potential need for expedited delivery if maternal or fetal conditions deteriorated. The team discussed the possibility of transferring Jessica to a tertiary care facility with a neonatal intensive care unit, in anticipation of an early delivery and the need for specialized care for the newborn.

Section 3

New Complications

On the fifth day of Jessica's hospital stay, her condition showed further signs of progression. Despite the administration of antibiotics and continued fetal monitoring, Jessica began to experience more frequent contractions, occurring every 5 minutes, and they were progressively becoming more intense. Her discomfort increased, and she reported feeling more pressure in her pelvis. A repeat cervical examination indicated that she was now dilated to 2 cm and was 70% effaced, suggesting that labor might be imminent despite the interventions.

New diagnostic results were obtained to assess the risk of infection and the overall status of both mother and fetus. The complete blood count revealed a slight increase in white blood cell count to 12.5 x10^3/uL, raising suspicion of subclinical infection. C-reactive protein levels were also elevated, providing further evidence of inflammatory processes. Fetal monitoring continued to show a stable heart rate pattern with moderate variability, but the ongoing contractions and cervical changes heightened concern for preterm delivery.

The healthcare team discussed the potential need for transferring Jessica to a tertiary care facility equipped with a neonatal intensive care unit, preparing for the possibility of delivering a preterm infant. Given the increased risk of infection and preterm labor, the team considered administering a second course of betamethasone to further promote fetal lung maturity, should delivery become unavoidable. Jessica was counseled on the current findings, the potential risks involved, and the plan for her care, which included close monitoring and preparedness for an expedited delivery if maternal or fetal conditions continued to change.

Section 4

New Complications

As Jessica's contractions increased in frequency and intensity, the healthcare team remained vigilant in monitoring both maternal and fetal well-being. Despite the administration of tocolytics, her contractions progressed to every 3-4 minutes, raising concerns about the inevitability of preterm labor. Jessica's discomfort was evident, and she reported significant pelvic pressure and lower back pain. A repeat cervical examination showed further cervical dilation to 3 cm, with 80% effacement, indicating progressive labor. Her vital signs showed a slight increase in heart rate at 110 bpm and a mildly elevated temperature of 99.5°F, which, combined with the elevated white blood cell count and C-reactive protein levels, suggested a possible underlying infection or inflammatory response.

New diagnostic results included a fetal fibronectin test, which returned positive, indicating an increased risk of imminent preterm delivery. Despite these findings, fetal monitoring continued to show reassuring heart rate patterns with moderate variability and no signs of fetal distress. However, the team recognized the increasing urgency to manage Jessica's condition proactively. Given the positive fetal fibronectin result and persistent cervical changes, the decision was made to transfer Jessica to a tertiary care facility with a neonatal intensive care unit to ensure both maternal and neonatal safety.

The healthcare team communicated the changes in Jessica's status and the rationale for transfer to her and her family, emphasizing the importance of a higher level of care for potential preterm delivery. Jessica expressed understanding and consented to the transfer. The team coordinated with the receiving facility to ensure a seamless transition, highlighting the need for continued close monitoring, possible administration of a second course of betamethasone, and readiness for expedited delivery if necessary. This decision marked a critical step in Jessica's care journey, prioritizing comprehensive support for both her and her unborn child during this challenging time.

Section 5

Change in Patient Status

Upon arrival at the tertiary care facility, Jessica was quickly reassessed. Her vital signs indicated a further increase in heart rate to 115 bpm and a temperature of 100.2°F, suggesting a possible progression of the underlying infection. Her blood pressure remained stable at 120/76 mmHg. A repeat cervical examination revealed continued dilation to 4 cm, and effacement had progressed to 90%, reinforcing the likelihood of preterm labor progression. Uterine contractions persisted at a frequency of every 3 minutes, with increased intensity noted by Jessica and confirmed by tocodynamometry.

Given the positive fetal fibronectin test from earlier and the continued cervical changes, the medical team initiated a second course of betamethasone to further enhance fetal lung maturity. An infectious workup was expanded to include blood cultures, and broad-spectrum antibiotics were started as a precautionary measure to address potential intra-amniotic infection, with a plan to tailor therapy based on culture results. Despite these interventions, Jessica's discomfort remained significant, requiring additional pain management strategies, including IV acetaminophen.

The multidisciplinary team, including neonatologists, obstetricians, and nurses, convened to discuss Jessica's care plan. The consensus was to continue close monitoring, maintaining readiness for possible preterm delivery. The team emphasized the importance of balancing the need for prolonging the pregnancy to improve neonatal outcomes against the risk of maternal and fetal complications from infection. As the team prepared for potential delivery, they ensured that all necessary resources, including neonatal resuscitation equipment and staff, were on standby to provide immediate care for Jessica's baby in the event of an imminent preterm birth.