A patient in preterm labor with a history of preeclampsia and gestational diabetes presents with contractions every five minutes, proteinuria, and elevated blood pressure. Which of the following nursing interventions is the priority to ensure maternal and fetal safety?

C) Administer antihypertensive medication to lower blood pressure.

A) Administer a tocolytic agent to stop contractions.

B) Adjust the insulin regimen to control blood glucose levels.

C) Administer antihypertensive medication to lower blood pressure.

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

A patient in preterm labor presents with increased uterine contractions every 2-3 minutes, variable decelerations on fetal heart tracing, and confirmed oligohydramnios. What is the priority nursing intervention to address the fetal heart rate changes?

A) Position the patient in left lateral position.

B) Increase the rate of oxytocin infusion.

C) Administer a bolus of IV fluids.

D) Prepare the patient for immediate cesarean delivery.

A patient in preterm labor is experiencing increased uterine contractions and variable decelerations on fetal heart rate tracing. An ultrasound confirms oligohydramnios. What is the most appropriate initial nursing intervention to address the fetal heart rate changes?

B) Reposition the patient to her left lateral side.

A) Increase the infusion rate of the tocolytic therapy.

B) Reposition the patient to her left lateral side.

C) Administer an additional dose of antihypertensive medication.

D) Prepare the patient for an immediate cesarean section.

A patient with suspected preeclampsia is receiving magnesium sulfate infusion. Which clinical finding would indicate the need to adjust the magnesium sulfate dosage?

A) Deep tendon reflexes are absent

B) Blood pressure decreases to 130/85 mmHg

C) Urine output is 40 mL per hour

D) Respiratory rate is 18 breaths per minute

A pregnant patient with suspected preeclampsia is receiving magnesium sulfate for seizure prophylaxis. Which clinical finding should the nurse immediately report to the healthcare provider as a possible sign of magnesium toxicity?

A) Respiratory rate of 12 breaths per minute

D) Blood pressure of 150/90 mmHg

A patient undergoing magnesium sulfate therapy for preterm labor is showing signs of magnesium toxicity, including diminished deep tendon reflexes rated as 1+. What is the nurse's priority action at this time?

D) Discontinue the magnesium sulfate infusion and notify the healthcare provider immediately

A) Continue monitoring the patient closely and reassess in 30 minutes

B) Administer calcium gluconate as an antidote to reverse magnesium sulfate toxicity

C) Increase the dosage of magnesium sulfate to stabilize preterm labor

D) Discontinue the magnesium sulfate infusion and notify the healthcare provider immediately

A patient receiving magnesium sulfate for preterm labor begins to exhibit signs of toxicity, including drowsiness, difficulty with speech, and diminished deep tendon reflexes. What is the most appropriate initial nursing action?

B) Reduce the rate of magnesium sulfate infusion

A) Administer calcium gluconate as an antidote

B) Reduce the rate of magnesium sulfate infusion

C) Monitor respiratory rate and oxygen saturation closely

D) Increase IV fluid rate to promote renal excretion

A patient receiving magnesium sulfate for severe preeclampsia has developed respiratory depression with a respiratory rate of 10 breaths per minute and an oxygen saturation of 89%. Her serum magnesium level is 9.5 mg/dL. Which initial nursing intervention is most appropriate?

B) Stop the magnesium sulfate infusion immediately

A) Administer supplemental oxygen via nasal cannula

B) Stop the magnesium sulfate infusion immediately

C) Prepare for potential intubation and mechanical ventilation

A 32-year-old pregnant patient receiving magnesium sulfate therapy for severe preeclampsia presents with a respiratory rate of 10 breaths per minute and an oxygen saturation of 89%. The serum magnesium level is 9.5 mg/dL. What is the most appropriate initial nursing intervention?

A) Increase the rate of magnesium sulfate infusion

C) Monitor the patient for further respiratory decline

D) Encourage deep breathing exercises to improve oxygenation

preterm labor - Nursing Case Study

Pathophysiology

• Primary mechanism: Inflammation and infection trigger preterm labor by activating the maternal immune response, leading to the release of pro-inflammatory cytokines. These cytokines stimulate uterine contractions, cervical ripening, and membrane rupture, accelerating labor onset.

• Secondary mechanism: Uteroplacental ischemia or stress can activate the hypothalamic-pituitary-adrenal (HPA) axis in both the mother and fetus. This activation increases corticotropin-releasing hormone (CRH) levels, promoting prostaglandin and oxytocin release, which further stimulates uterine contractions.

• Key complication: Untimely labor can result in neonatal respiratory distress syndrome due to insufficient surfactant production in the premature lungs, underlining the importance of timely antenatal corticosteroid administration.

Patient Profile

Demographics:

32-year-old female, elementary school teacher

History:

• Key past medical history: History of preeclampsia during a previous pregnancy, gestational diabetes

• Current medications: Prenatal vitamins, insulin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Regular contractions and lower abdominal pain

• Key symptoms: Increasing frequency of contractions, back pain, mild vaginal bleeding

• Vital signs: Blood pressure 145/95 mmHg, heart rate 105 bpm, temperature 98.9°F, respiratory rate 22 breaths per minute

Section 1

As the healthcare team conducts an initial assessment, they note that the patient's contractions are occurring every five minutes and lasting approximately 60 seconds. The lower abdominal pain is described as cramping, and the back pain is persistent. Upon examination, the cervix is found to be 3 cm dilated and 80% effaced, indicating that labor is progressing. The fetal heart rate, monitored via an external fetal monitor, shows moderate variability with occasional early decelerations, suggesting increased uterine activity but no immediate fetal distress.

Given the patient's history of preeclampsia and gestational diabetes, the medical team is particularly vigilant. A urine dipstick test reveals proteinuria, while blood tests show elevated glucose levels at 160 mg/dL, warranting adjustments to her insulin regimen to better control her blood sugar levels. Additionally, her blood pressure remains elevated despite rest, raising concerns about the potential recurrence of preeclampsia. To mitigate the risk of neonatal complications, the healthcare team administers a course of antenatal corticosteroids to accelerate fetal lung maturity.

The patient's condition prompts further diagnostic evaluations, including a complete blood count (CBC), which reveals a mild leukocytosis with a white blood cell count of 15,000/mm³, suggesting a possible infectious process contributing to labor onset. C-reactive protein (CRP) levels are also elevated, supporting the inflammatory component of her presentation. To address the risk of infection, a decision is made to initiate a broad-spectrum antibiotic regimen while awaiting culture results. The team remains vigilant for signs of chorioamnionitis and closely monitors both maternal and fetal well-being as they navigate the complexities of managing preterm labor in this high-risk patient.

Section 2

As the healthcare team closely monitors the patient's condition, they observe a change in her status that prompts immediate attention. The patient's contractions have increased in frequency, now occurring every two to three minutes and lasting 70 seconds. This escalation in uterine activity corresponds with a noticeable increase in discomfort reported by the patient, who describes intensified lower abdominal cramping and persistent back pain. Additionally, her blood pressure readings remain elevated at 150/95 mmHg despite previous interventions, raising further concerns about the management of her hypertensive state.

The fetal heart rate tracing reveals subtle changes, with the development of variable decelerations that suggest the possibility of umbilical cord compression. Although the variability remains moderate, the team is alert to the potential for fetal compromise. Concurrently, the patient's oxygen saturation has slightly decreased to 95%, prompting the administration of supplemental oxygen to optimize oxygen delivery to both mother and fetus. The healthcare team reassesses the effectiveness of the interventions in place, considering adjustments to the tocolytic therapy to help manage the contractions and potentially delay labor progression.

In light of these developments, the team decides to conduct a bedside ultrasound to evaluate the amniotic fluid index, suspecting oligohydramnios as a contributing factor to the variable decelerations. The ultrasound confirms a reduced amniotic fluid level, consistent with oligohydramnios, which necessitates further evaluation of the potential causes and implications for ongoing labor management. This finding, combined with the patient's complex clinical picture, requires the team to continuously reassess and adapt their management strategy to balance maternal and fetal well-being as they prepare for possible delivery in the context of preterm labor.

Section 3

As the healthcare team continues to monitor the patient, they observe a concerning change in her status. Despite the administration of tocolytic therapy, the patient's contractions have not abated; instead, they have become more intense and frequent. The patient now rates her pain at 8 out of 10 on the pain scale, and her discomfort is compounded by the persistent back pain. Her blood pressure remains elevated, with a new reading of 155/98 mmHg, indicating that the hypertensive state needs more aggressive management. The patient is also displaying signs of increasing anxiety, which may contribute to her elevated blood pressure and pain perception.

Additional diagnostic tests are conducted to understand the developing clinical picture. Blood tests reveal a mild elevation in liver enzymes, with AST and ALT levels slightly above normal, raising the suspicion of preeclampsia superimposed on chronic hypertension. The urine protein test shows 1+ proteinuria, further supporting this concern. In light of these findings, the healthcare team considers the potential need for magnesium sulfate administration to address both seizure prophylaxis and neuroprotection for the fetus, given the risk of imminent preterm delivery.

In response to these developments, the team prioritizes the stabilization of the patient's condition. They initiate a magnesium sulfate infusion to manage the potential preeclampsia and reduce the risk of eclamptic seizures. Simultaneously, they adjust the tocolytic regimen, opting for a different class of medication in hopes of reducing uterine activity. The team also prepares for the possibility of an expedited delivery, ensuring that neonatal care specialists are on standby. As these interventions are implemented, the team remains vigilant, reassessing the patient's response and the fetal status to ensure that both mother and baby are receiving optimal care despite the challenging clinical scenario.

Section 4

As the healthcare team continues to monitor the patient, they observe a notable change in her status following the initiation of magnesium sulfate and the revised tocolytic therapy. Within a few hours, the patient's contractions begin to decrease in intensity and frequency, offering a glimmer of hope that the preterm labor might be stabilizing. However, new challenges arise as the patient begins to exhibit signs of magnesium sulfate toxicity. She reports feeling increasingly drowsy and experiences mild difficulty with speech. A focused neurological assessment reveals diminished deep tendon reflexes, which are now rated as 1+ bilaterally, indicating the need for careful monitoring of magnesium levels and potential dosage adjustment.

Concurrently, fetal monitoring presents a mixed picture. While there is reassuring variability in the fetal heart rate, the presence of occasional late decelerations prompts the team to remain cautious. The decision is made to closely observe for any further signs of fetal distress, keeping in mind the delicate balance between prolonging the pregnancy and ensuring the well-being of both mother and child. The patient's blood pressure remains elevated, despite the previously administered medications, with a current reading of 160/100 mmHg. This persistent hypertension necessitates an escalation in antihypertensive therapy, carefully balancing the need to manage maternal blood pressure while avoiding any adverse effects on uteroplacental perfusion.

In conclusion, the response to the interventions presents a complex scenario that requires ongoing vigilance and adaptability. The team must continuously evaluate the benefits and risks of each therapeutic decision, considering the evolving clinical picture. The immediate focus is on optimizing maternal conditions to prevent further complications, while also preparing for potential delivery should the fetal or maternal status warrant it. The interdisciplinary approach underscores the importance of cohesive teamwork, with each member of the healthcare team contributing to the shared goal of achieving the best possible outcome for both mother and baby.

Section 5

As the healthcare team continues to manage the patient, a new complication arises that heightens the urgency of the situation. Approximately five hours after the initiation of magnesium sulfate therapy, the patient develops increasing respiratory difficulty, marked by a respiratory rate of 10 breaths per minute and shallow respirations. Her oxygen saturation drops to 89% on room air, prompting the team to initiate supplemental oxygen and prepare for potential respiratory support. This development signifies an escalation of magnesium toxicity, necessitating an immediate re-evaluation of her treatment plan. A serum magnesium level is drawn urgently, revealing a level of 9.5 mg/dL, confirming the clinical suspicion of toxicity. The decision is made to halt the magnesium sulfate infusion and administer calcium gluconate as an antidote while closely monitoring her respiratory and neurological status.

Simultaneously, the fetal monitoring strip indicates a concerning trend. The previously reassuring variability in the fetal heart rate begins to diminish, and the frequency of late decelerations increases. These changes suggest potential fetal compromise, possibly linked to maternal hypoxemia and the ongoing hypertensive crisis. The fetal heart rate is recorded at 110-120 bpm, a bradycardic trend that prompts the team to reassess the risk of continuing the pregnancy versus the benefits of immediate intervention. The maternal blood pressure remains elevated at 165/105 mmHg despite the escalation in antihypertensive therapy, raising concerns about the risk of placental insufficiency and further fetal jeopardy.

In light of these developments, the healthcare team convenes for a multidisciplinary discussion to formulate a revised plan of care. The immediate priorities include stabilizing the maternal respiratory status, optimizing blood pressure control, and deciding on the timing and mode of delivery to ensure the best possible outcome for both mother and child. The team prepares for the potential need for an emergent cesarean section, should the fetal or maternal condition not improve with current interventions. This complex clinical scenario underscores the need for precise clinical reasoning and swift decision-making to navigate the intricate balance of risks and benefits in managing preterm labor with associated complications.