A patient in labor with a history of gestational diabetes and current hypertension is experiencing irregular contractions and signs of fetal distress. The healthcare team has initiated a low-dose oxytocin infusion and magnesium sulfate. Which nursing intervention should be prioritized to address potential complications in this scenario?

B) Administer an antihypertensive medication as ordered to control maternal blood pressure

A) Increase the rate of oxytocin infusion to enhance contraction strength

B) Administer an antihypertensive medication as ordered to control maternal blood pressure

C) Encourage the patient to ambulate to promote labor progression

D) Prepare the patient for an immediate cesarean section due to fetal distress

A patient in labor with a history of gestational diabetes and hypertension is experiencing irregular contractions and fetal heart rate variability with intermittent late decelerations. After the administration of oxytocin, her blood pressure remains at 155/100 mmHg, and she reports a mild headache. Magnesium sulfate infusion has been started. What is the nurse's priority action to ensure both maternal and fetal safety?

C) Continue to monitor the fetal heart rate and maternal blood pressure closely.

A) Increase the oxytocin infusion to enhance contraction strength.

B) Prepare the patient for potential cesarean section due to suspected preeclampsia.

C) Continue to monitor the fetal heart rate and maternal blood pressure closely.

D) Administer an antihypertensive medication to lower the patient's blood pressure immediately.

A pregnant patient with severe preeclampsia and suspected HELLP syndrome is being managed with magnesium sulfate. Her condition is worsening, with further elevated blood pressure, visual disturbances, and fetal heart rate decelerations. What is the most appropriate nursing action at this time?

B) Prepare the patient for an emergency cesarean section to ensure maternal and fetal safety.

A) Increase the dosage of magnesium sulfate to manage the elevated blood pressure.

B) Prepare the patient for an emergency cesarean section to ensure maternal and fetal safety.

C) Administer antihypertensive medication to immediately lower the blood pressure.

D) Initiate continuous fetal monitoring and wait for further instructions from the physician.

A patient with severe preeclampsia and suspected HELLP syndrome presents with elevated blood pressure, visual disturbances, and fetal distress. Which nursing intervention is most critical to prioritize before proceeding with an emergency cesarean section?

C) Ensure intravenous access and prepare for potential blood transfusion.

A) Administer additional magnesium sulfate to prevent seizures.

B) Initiate continuous electronic fetal monitoring to assess fetal status.

C) Ensure intravenous access and prepare for potential blood transfusion.

D) Educate the patient about the risks and benefits of the cesarean section procedure.

A nurse is caring for a patient, Sarah, who is experiencing respiratory distress due to pulmonary edema related to severe preeclampsia and magnesium sulfate infusion. Which of the following interventions should the nurse prioritize to address Sarah's respiratory status?

B) Administer supplemental oxygen via non-rebreather mask

A) Increase the rate of intravenous fluids to maintain blood pressure

B) Administer supplemental oxygen via non-rebreather mask

C) Discontinue the magnesium sulfate infusion immediately

D) Initiate continuous fetal monitoring and delay respiratory intervention

A nurse is managing a patient with severe preeclampsia who is experiencing respiratory distress and has been on magnesium sulfate infusion. The patient shows bilateral crackles on lung auscultation, a respiratory rate of 28 breaths per minute, and oxygen saturation of 92% on room air. Which of the following actions should the nurse prioritize to address the patient's respiratory distress?

C) Provide supplemental oxygen via a non-rebreather mask.

A) Administer an antihypertensive to reduce blood pressure.

B) Increase the rate of the magnesium sulfate infusion.

C) Provide supplemental oxygen via a non-rebreather mask.

D) Encourage the patient to take deep breaths and cough.

A nurse is caring for Sarah, who is experiencing respiratory distress and pulmonary edema despite supplemental oxygen. Which intervention should the nurse prioritize to address Sarah's current condition while minimizing risks to fetal well-being?

A) Administer diuretics to reduce pulmonary fluid overload.

B) Increase the oxygen flow rate to improve oxygen saturation.

C) Prepare for emergency cesarean section to address fetal distress.

D) Adjust the magnesium sulfate infusion to target therapeutic levels.

A nurse is caring for a pregnant patient, Sarah, with persistent respiratory distress and suspected pulmonary edema. Despite administering supplemental oxygen, the patient's oxygen saturation remains at 92%. A chest X-ray reveals bilateral infiltrates. Which nursing intervention should the nurse prioritize to address Sarah's respiratory status while minimizing risks to the fetus?

C) Prepare and administer a diuretic as ordered to reduce fluid overload.

A) Administer a bolus of intravenous fluids to improve circulation.

B) Increase the rate of oxygen flow to improve oxygenation.

C) Prepare and administer a diuretic as ordered to reduce fluid overload.

D) Position the patient in a supine position to enhance uteroplacental perfusion.

A nurse is caring for Sarah, a patient experiencing worsening respiratory distress and pulmonary edema. After administering furosemide, the nurse observes a slight improvement in Sarah's respiratory status but notes her urine output is marginal. What is the next best nursing action to ensure adequate renal perfusion and function?

C) Notify the healthcare provider about the marginal urine output for further evaluation.

A) Increase the rate of intravenous fluids to improve urine output.

B) Monitor serum electrolytes and adjust diuretic dosage based on results.

C) Notify the healthcare provider about the marginal urine output for further evaluation.

D) Encourage oral fluid intake to enhance diuresis and renal perfusion.

A nurse is assessing Sarah, who is experiencing worsening respiratory distress and pulmonary edema. After administering a low dose of furosemide, the nurse observes a slight improvement in her respiratory status. Which additional assessment finding should be the nurse's priority to report to the healthcare provider?

A) Blood pressure increase to 170/115 mmHg

B) Urine output of 40 mL over the past hour

C) Oxygen saturation of 92% on supplemental oxygen

D) Slightly diminished deep tendon reflexes

Intrapartum - Nursing Case Study

Pathophysiology

• Primary mechanism: Uterine Contractions - During intrapartum, rhythmic contractions of the uterine muscles are crucial for cervical dilation and fetal descent. These contractions are driven by the hormone oxytocin, leading to increased intrauterine pressure that facilitates labor progression.

• Secondary mechanism: Cervical Effacement and Dilation - The cervix undergoes effacement (thinning) and dilation (opening) as it responds to the pressure from uterine contractions and fetal head engagement. This process is essential for creating a passage through which the fetus can be delivered.

• Key complication: Fetal Distress - In cases of prolonged or excessively strong contractions, there is a risk of compromised fetal oxygenation, leading to fetal distress. This requires careful monitoring and potential intervention to ensure both maternal and fetal safety during labor.

Patient Profile

Demographics:

32 years old, female, school teacher

History:

• Key past medical history: Gestational diabetes in previous pregnancy, hypertension

• Current medications: Labetalol, prenatal vitamins

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Prolonged labor with inadequate progress

• Key symptoms: Increasing fatigue, back pain, mild headache

• Vital signs: Blood pressure 150/95 mmHg, heart rate 110 bpm, respiratory rate 20 breaths per minute, temperature 37.8°C (100°F)

Section 1

As the labor progresses, the healthcare team performs an initial assessment to evaluate the current status of both the mother and the fetus. Upon examination, the cervix is found to be 4 cm dilated and 70% effaced, indicating that labor is not progressing as expected given the duration. The patient's contraction pattern is assessed using a fetal monitor, which reveals frequent, yet irregular contractions that are not sufficiently strong to promote effective cervical dilation. The fetal heart rate monitoring shows signs of variability, with intermittent late decelerations, suggesting the possibility of fetal distress.

In light of the concerning fetal heart patterns and lack of labor progression, the team considers potential interventions. Given the patient's history of gestational diabetes and current hypertension, the risk of complications such as preeclampsia is increased. A decision is made to administer a low-dose oxytocin infusion to enhance contraction effectiveness, while closely monitoring maternal blood pressure and fetal response. The patient's lab results are reviewed, showing mildly elevated liver enzymes and proteinuria, further raising suspicion of preeclampsia and necessitating vigilant observation for any further deterioration in maternal condition.

Despite these interventions, the patient's blood pressure remains elevated at 155/100 mmHg, and the mild headache persists, suggesting worsening hypertension. A magnesium sulfate infusion is initiated as a prophylactic measure against eclamptic seizures, while continuous fetal monitoring is maintained. The healthcare team discusses the possibility of escalating to a cesarean section if maternal or fetal distress worsens. This situation calls for careful clinical reasoning to balance the risks and benefits of continued labor versus surgical intervention, as both maternal and fetal well-being are at stake.

Section 2

As the magnesium sulfate infusion is administered to manage the risk of eclamptic seizures, the healthcare team closely monitors the patient's response to the intervention. Despite the proactive measures, the patient's condition begins to change subtly yet significantly. Her blood pressure remains elevated, now reading 160/105 mmHg, and she reports increased visual disturbances, including seeing spots. These symptoms, alongside the previous findings of proteinuria and elevated liver enzymes, heighten the suspicion of severe preeclampsia. Furthermore, the fetal heart rate continues to show intermittent late decelerations, raising concerns about fetal oxygenation and the possibility of impending fetal distress.

The latest lab results indicate a further rise in liver enzymes, with AST and ALT now reaching 95 U/L and 100 U/L, respectively, along with a platelet count that has started to decline, suggesting the development of HELLP syndrome. The team must quickly re-evaluate the situation, weighing the risks of continued labor against the need for urgent delivery. The patient's cervix has progressed to only 5 cm dilation with continued inadequate contraction strength, indicating that labor is unlikely to progress swiftly enough to resolve the growing maternal-fetal compromise.

Given the escalating severity of the maternal condition and the persistent signs of fetal distress, the healthcare team engages in thorough clinical reasoning to determine the most appropriate course of action. The decision is made to proceed with an emergency cesarean section to protect both the mother and the fetus from further harm. The team prepares for the procedure, ensuring that all necessary personnel and resources are available to manage potential complications, such as maternal bleeding or fetal resuscitation, that could arise during the surgical delivery. This decision highlights the critical importance of timely intervention in the context of deteriorating maternal and fetal health, emphasizing the need for precise clinical judgment and swift action.

Section 3

As the healthcare team swiftly transitions to prepare for the emergency cesarean section, a new complication emerges that demands immediate attention. The nurse notes that the patient, Sarah, is experiencing increased respiratory distress, with a respiratory rate rising to 28 breaths per minute and oxygen saturation dropping to 92% on room air. Auscultation of her lungs reveals bilateral crackles, suggesting the development of pulmonary edema, likely exacerbated by the fluid shifts associated with severe preeclampsia and the intravenous magnesium sulfate infusion. Recognizing the emergent nature of this complication, the team administers supplemental oxygen via a non-rebreather mask and adjusts the fluid management plan to prevent further fluid overload.

Simultaneously, Sarah's neurological status is carefully monitored, given her increased risk of eclamptic seizures. Despite the magnesium sulfate infusion, she exhibits heightened deep tendon reflexes, rated at 3+ on the scale, indicating a need to reassess the magnesium levels to ensure therapeutic range is maintained without reaching toxic levels. The lab results confirm a magnesium level of 5.5 mg/dL, necessitating the continued close monitoring of both neurologic and renal function to prevent complications such as respiratory paralysis or oliguria.

As preparations for the cesarean section continue, the fetal heart rate monitor reveals persistent late decelerations, with a baseline heart rate of 110 bpm and minimal variability, underscoring the urgency of the situation. The fetal scalp pH test, performed to assess fetal acid-base status, returns a concerning value of 7.20, indicating significant fetal acidosis. These findings reinforce the necessity of immediate surgical intervention to prevent further compromise to the fetus. The team ensures that neonatal resuscitation equipment is prepared, anticipating the potential need for advanced neonatal care post-delivery. This comprehensive approach to the evolving clinical scenario emphasizes the critical role of dynamic clinical reasoning and interdisciplinary collaboration in managing complex intrapartum complications.

Section 4

As the healthcare team continues to manage Sarah's condition, a new complication emerges. Despite the administration of supplemental oxygen, her oxygen saturation remains at 92%, and her respiratory distress persists. The team is concerned about Sarah's fluid status and the possibility of worsening pulmonary edema. A chest X-ray is ordered and reveals bilateral infiltrates consistent with pulmonary edema, confirming the need for immediate intervention to optimize her respiratory function. Diuretics are considered to manage the fluid overload, but the team must carefully balance the risk of reducing circulating volume, which could compromise uteroplacental perfusion.

Sarah's neurological status remains a point of concern. Despite the magnesium sulfate infusion, the heightened deep tendon reflexes and her lab results suggest the magnesium level is not yet in the therapeutic range to fully prevent seizures. The decision is made to increase the magnesium sulfate infusion rate slightly, while closely monitoring her renal function to prevent any potential complications such as oliguria. The nursing team remains vigilant for any signs of magnesium toxicity, such as diminished reflexes or respiratory depression, given the narrow therapeutic window.

As the cesarean section draws nearer, the fetal heart rate monitor continues to display late decelerations, with persistent minimal variability. The obstetrician and anesthesiologist discuss the urgency of proceeding with the delivery, emphasizing the need for a controlled and swift surgical approach to mitigate further fetal compromise. The team prepares for potential neonatal resuscitation, with the neonatologist ready to address the possible consequences of significant fetal acidosis. This scenario highlights the critical need for precise clinical reasoning and the coordination of multidisciplinary efforts to navigate the complexities of Sarah's intrapartum care.

Section 5

As the healthcare team closely monitors Sarah, a change in her status becomes noticeable, prompting immediate attention. Her respiratory distress intensifies, and her oxygen saturation drops further to 89%, despite the supplemental oxygen. Her respiratory rate has increased to 28 breaths per minute, indicating worsening respiratory compromise. Auscultation of the lungs reveals crackles throughout both lung fields, suggesting an escalation in pulmonary edema. Concurrently, her blood pressure rises to 160/110 mmHg, exacerbating concerns about her fluid status and potential effects on her cardiovascular system.

In light of these developments, the medical team decides to administer a low dose of furosemide to alleviate the pulmonary congestion while closely monitoring her blood pressure and urine output to avoid compromising uteroplacental perfusion. The team notes a slight improvement in her respiratory status and oxygen saturation, which rises to 92% after the diuretic is administered. However, her urine output remains marginal, and her renal function is carefully evaluated with a serum creatinine level of 1.2 mg/dL, slightly above the normal range. This necessitates continued vigilance to prevent renal complications while managing the fluid overload.

Simultaneously, attention is drawn to Sarah's neurological status. The increase in magnesium sulfate appears effective as her deep tendon reflexes are now slightly diminished, suggesting the magnesium levels are approaching therapeutic range. However, the team remains cautious, observing for any signs of magnesium toxicity. The multidisciplinary team, including obstetricians, anesthesiologists, and neonatologists, prepares to proceed with the cesarean section, recognizing the need for a delicate balance between managing Sarah's condition and ensuring fetal well-being. This situation underscores the importance of precise clinical judgment and collaboration to address the evolving complexities in Sarah's care.