A patient in the pre-operative unit is preparing for a cervical cerclage due to cervical incompetence. Her vital signs show a heart rate of 102 bpm and blood pressure of 100/65 mmHg. A repeat ultrasound reveals cervical shortening to 15 mm with increased funnelling and dilation. What is the most appropriate nursing intervention to ensure patient safety and readiness for the procedure?

A) Administer a bolus of intravenous fluids to address potential dehydration.

B) Request an immediate consultation with an anesthesiologist to reassess anesthesia plans.

C) Educate the patient about the procedure and provide emotional support to reduce anxiety.

D) Hold the procedure and notify the healthcare provider to evaluate the need for intravenous tocolytics.

A pregnant patient undergoing pre-operative assessment for a cervical cerclage exhibits a slight increase in heart rate and a decrease in blood pressure. Upon further evaluation, no overt signs of dehydration or stress were found. A repeat transvaginal ultrasound showed a further shortened cervix with increased funnelling. What is the most appropriate nursing action to take in response to these findings?

C) Prepare the patient for the cerclage procedure while monitoring vital signs closely.

A) Administer intravenous fluids to address potential dehydration.

B) Recommend postponing the procedure until the patient's vital signs stabilize.

C) Prepare the patient for the cerclage procedure while monitoring vital signs closely.

D) Notify the physician of the changes in vital signs and request additional tests.

A patient who recently underwent a cervical cerclage procedure is experiencing mild lower abdominal discomfort and an increase in light pink vaginal discharge. Which nursing intervention is most appropriate at this time to address the patient's symptoms?

C) Initiate prophylactic antibiotic therapy as ordered and monitor for signs of infection.

A) Administer an analgesic for pain relief and observe for changes.

B) Encourage ambulation to alleviate discomfort and promote circulation.

C) Initiate prophylactic antibiotic therapy as ordered and monitor for signs of infection.

D) Increase fluid intake to promote hydration and monitor urinary output.

A patient who recently underwent a cervical cerclage procedure is experiencing mild lower abdominal discomfort and an increase in light pink vaginal discharge. Which nursing intervention should be prioritized to address potential complications?

A) Administer prescribed prophylactic antibiotics and monitor for signs of infection.

B) Increase IV fluid rate to address potential dehydration and observe for changes in vital signs.

C) Educate the patient about activity restrictions to prevent cerclage dislodgement.

D) Reassure the patient that mild discomfort and discharge are normal post-operative findings.

A patient one week post-operative after cerclage placement presents with a resurgence of lower abdominal pain and a low-grade fever. The CBC shows slight leukocytosis, and the CRP is elevated. What is the most appropriate nursing action to prioritize in this situation?

A) Administer the prescribed broad-spectrum antibiotics and monitor the patient’s response

B) Educate the patient on the importance of hydration to reduce fever

C) Reassure the patient that mild discomfort is normal post-procedure and advise rest

D) Encourage the patient to apply a warm compress to the abdomen to relieve pain

A patient who underwent prophylactic antibiotic treatment post-operatively is now presenting with resurgence of symptoms, including lower abdominal pain and a low-grade fever, a week later. The healthcare team suspects an infection or inflammatory response. As a nurse, what is the most appropriate initial intervention to assist in managing this patient's current condition?

A) Administer the prescribed broader spectrum antibiotics and monitor for side effects.

B) Encourage the patient to apply a warm compress to the abdominal area to alleviate discomfort.

C) Advise the patient to increase fluid intake to help reduce fever and support hydration.

D) Educate the patient on performing abdominal exercises to reduce edema and improve circulation.

A patient under treatment for infection related to a cerclage site is showing modest improvement with a reduction in abdominal pain and fever. Which of the following should the nurse prioritize in the ongoing care plan to ensure the patient's and fetus's safety?

B) Provide education on recognizing signs of infection and complications.

A) Encourage the patient to increase physical activity to promote circulation.

B) Provide education on recognizing signs of infection and complications.

C) Discontinue the current antibiotic therapy to prevent resistance.

D) Schedule an immediate ultrasound to check for fetal development progress.

A patient receiving treatment for an infection after a cerclage procedure reports decreased abdominal pain and a reduction in fever. Laboratory tests show a slight decrease in white blood cell count and CRP level. However, an ultrasound indicates persistent mild edema. Which nursing intervention is most appropriate at this time?

B) Educate the patient on monitoring symptoms and when to seek immediate medical attention.

A) Discontinue the current antibiotic regimen.

B) Educate the patient on monitoring symptoms and when to seek immediate medical attention.

C) Increase the dosage of anti-inflammatory medication.

D) Schedule an immediate surgical consultation to assess the cerclage.

A patient with a cervical cerclage presents with mild abdominal discomfort, bloody vaginal discharge, and a slight increase in cervical dilation. The healthcare team decides to initiate tocolytics and antenatal corticosteroids. What is the primary nursing intervention to prevent further complications in this scenario?

C) Reinforce the need for strict bed rest and limited activity.

A) Encourage frequent ambulation to promote circulation.

B) Educate the patient on the importance of fluid restriction.

C) Reinforce the need for strict bed rest and limited activity.

D) Administer antibiotics to prevent potential infection.

A patient with a cervical cerclage presents with increased vaginal discharge tinged with blood, mild abdominal discomfort, and slight cervical dilation. Which nursing intervention is most appropriate to prioritize in this situation?

C) Administer prescribed tocolytics and corticosteroids and monitor fetal heart rate and uterine activity closely.

A) Encourage the patient to ambulate regularly to prevent blood clots.

B) Prepare the patient for immediate removal of the cerclage to prevent further complications.

C) Administer prescribed tocolytics and corticosteroids and monitor fetal heart rate and uterine activity closely.

D) Advise the patient to increase fluid intake and monitor for signs of dehydration.

Pre-Operative Incompetent Cervix A 30-year-old female, G3P1, was admitted at 18 weeks gestation due to a history of recurrent mid-trimester pregnancy loss. She previously experienced a miscarriage at 20 weeks and had a preterm birth at 32 weeks. The patient reported increased vaginal discharge but no pain or contractions. A transvaginal ultrasound showed a short cervix measuring 18 mm with funnelling and 2 cm dilation, indicative of cervical insufficiency. Physical examination confirmed a soft cervix without active contractions or infection. Her vital signs were stable. Pre-operative diagnostic tests included a CBC, urinalysis, and cervical culture, all of which were within normal limits, ruling out infection. Given the high risk for pregnancy loss, the patient was scheduled for a cervical cerclage (McDonald or Shirodkar technique) under regional anesthesia. - Nursing Case Study

Pathophysiology

• Primary mechanism: Cervical Structural Weakness

The cervix lacks the ability to maintain closure due to insufficient structural integrity, often stemming from collagen disorders, trauma, or congenital abnormalities, leading to premature dilation and effacement.

• Secondary mechanism: Increased Intrauterine Pressure

As the pregnancy progresses, the growing fetus and amniotic fluid increase pressure on the cervix. This pressure exacerbates the weak cervical structure, causing it to open prematurely without contractions.

• Key complication: Risk of Mid-Trimester Pregnancy Loss

If untreated, the incompetent cervix can lead to recurrent mid-trimester pregnancy loss or preterm birth due to its inability to retain the pregnancy until term. Cervical cerclage aims to provide mechanical support to prevent these outcomes.

Patient Profile

Demographics:

30-year-old female, occupation not specified

History:

• Gravida 3, Para 1, history of recurrent mid-trimester pregnancy loss

• No current medications reported

• No known allergies

Current Presentation:

• Chief complaint: Increased vaginal discharge

• Key symptoms: Short cervix with funnelling and dilation, history of pregnancy loss

• Vital signs: Blood pressure 110/70 mmHg, heart rate 90 bpm, respiratory rate 18 breaths per minute, temperature 98.6°F; note that patient may develop abnormal vitals such as slightly elevated heart rate or mild hypotension if complications arise during treatment

Section 1

As the patient prepared for her scheduled cervical cerclage, her condition was closely monitored in the pre-operative unit. Despite stable vital signs initially, a slight change developed just before the procedure. The patient's heart rate increased to 102 bpm and her blood pressure dropped to 100/65 mmHg, raising mild concerns about potential hemodynamic instability. These changes, although minor, prompted further evaluation to ensure that she remained a suitable candidate for the surgical intervention. The nursing team conducted an additional assessment, focusing on signs of dehydration or stress which could contribute to these variations in vital signs, but found no overt clinical signs such as dry mucous membranes or altered mental status.

The healthcare team decided to proceed with an additional diagnostic evaluation. A repeat transvaginal ultrasound was performed to reassess the cervical length and funnelling. The ultrasound revealed that the cervix had shortened further to 15 mm, with increased funnelling and dilation now at 2.5 cm. This progression confirmed the urgency of performing the cerclage to prevent further cervical incompetence and potential pregnancy loss. Informed by these findings, the decision was made to continue with the cerclage under regional anesthesia, while monitoring the patient closely for any further changes in her condition.

This development emphasized the importance of timely intervention and highlighted the need for ongoing vigilance in monitoring the patient's status. The slight changes in vital signs were interpreted as a possible stress response or early indicator of hemodynamic shifts due to her cervical condition. This situation invited clinical reasoning regarding the balance between waiting for spontaneous labor signs and intervening surgically to prevent pregnancy loss, leading naturally to the next phase of her management where the efficacy and impact of the cerclage procedure would be assessed.

Section 2

Following the decision to proceed with the cerclage, the patient was transferred to the operating room. Throughout the procedure, her vital signs were continuously monitored. The regional anesthesia was administered successfully, and she remained stable, with her heart rate maintaining around 100 bpm and blood pressure stabilizing at 105/68 mmHg. The cerclage was performed using the McDonald technique, and there were no immediate intraoperative complications. However, shortly after the procedure, while in the recovery area, the patient began experiencing mild lower abdominal discomfort and a slight increase in vaginal discharge, now tinged with light pink, which prompted further evaluation.

The post-operative ultrasound was conducted to assess the cerclage placement and check for any immediate post-surgical complications. The results showed that the cerclage was appropriately placed, and the cervical length was maintained at 15 mm with no further funnelling or dilation. Despite these reassuring findings, the patient's abdominal discomfort and increase in discharge warranted additional investigation. A repeat CBC was ordered to rule out any signs of infection or unexpected blood loss, revealing a slight drop in hemoglobin from 12.5 g/dL pre-operatively to 11.8 g/dL post-operatively, which, although within acceptable limits, suggested a mild physiological response to the surgical intervention.

This development required clinical reasoning to determine the cause of her symptoms, whether they were related to the surgical procedure or an early sign of another complication such as infection or irritation from the cerclage. The healthcare team decided to initiate prophylactic antibiotics to prevent any potential infection and scheduled close follow-up appointments to monitor the patient's recovery and the ongoing status of the pregnancy. This approach aimed to address the current symptoms while preventing further complications, underscoring the importance of proactive management and vigilant monitoring in ensuring a favorable outcome for both the patient and her pregnancy.

Section 3

The patient's initial response to the prophylactic antibiotics was positive, with a reduction in abdominal discomfort and stabilization of her vaginal discharge, which returned to its pre-operative state. However, during a routine follow-up visit a week later, the patient reported a resurgence of lower abdominal pain, now more pronounced and persistent, accompanied by a low-grade fever of 38.2°C (100.8°F). Her vital signs were otherwise stable, with a heart rate of 98 bpm and blood pressure at 110/70 mmHg. Given these symptoms, the healthcare team suspected a possible infection or inflammatory response despite the initial prophylactic measures.

A new set of laboratory tests was ordered, including a comprehensive metabolic panel (CMP), repeat CBC, and an inflammatory marker panel, specifically focusing on C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). The CBC showed a slight leukocytosis with a white blood cell count of 12,000/mm³, indicating a potential infectious or inflammatory process. The CRP level was elevated at 25 mg/L, reinforcing the suspicion of underlying inflammation. The cerclage site was carefully examined via ultrasound, which showed no signs of displacement or further cervical changes, but mild surrounding tissue edema was noted.

These findings prompted the clinical team to revise their management strategy. They decided to switch the antibiotic regimen to a broader spectrum to cover potential resistant organisms and considered the introduction of anti-inflammatory medication to address the patient's symptoms. The team also educated the patient on recognizing signs of worsening symptoms, emphasizing the importance of immediate medical attention if her condition deteriorated. This plan aimed to address the current complications while maintaining close surveillance, ensuring any further issues could be promptly identified and managed, thus safeguarding the patient's pregnancy.

Section 4

As the patient continued under close observation, her response to the updated treatment plan was closely monitored. Two days after the new antibiotic regimen and introduction of anti-inflammatory medication, the patient reported a modest improvement in her symptoms. Her abdominal pain had decreased in intensity, though not completely resolved, and her fever had subsided to 37.5°C (99.5°F). Despite these encouraging signs, her clinical team remained vigilant, aware that the situation required ongoing assessment to prevent further complications.

During a follow-up evaluation, a repeat set of laboratory tests was conducted to gauge the effectiveness of the interventions. The CBC revealed a slight decrease in white blood cell count to 10,800/mm³, suggesting a positive response to the antibiotic therapy. Additionally, the CRP level dropped to 15 mg/L, indicating a reduction in inflammation. Despite these improvements, the ultrasound examination still showed persistent mild edema around the cerclage site. The patient's vital signs remained stable, with a heart rate of 94 bpm and blood pressure at 112/72 mmHg.

The team considered these developments cautiously optimistic, yet they decided to maintain the current treatment protocol while emphasizing the need for the patient to continue monitoring her symptoms closely. They reinforced the education provided earlier, ensuring she understood the importance of reporting any new or worsening symptoms, such as increased pain, fever, or unusual discharge. This approach aimed to sustain her progress and safeguard the pregnancy, while the healthcare team planned for further follow-up, including another comprehensive evaluation in a week's time to assess long-term outcomes and adjust care as necessary.

Section 5

Two days after the follow-up evaluation, the patient experienced a sudden change in her status, prompting an immediate reassessment by the clinical team. She reported a significant increase in vaginal discharge, now tinged with blood, and described a return of abdominal discomfort, albeit mild. Her temperature remained stable at 37.3°C (99.1°F), but her heart rate had risen to 102 bpm, and she exhibited mild tachycardia. Blood pressure was recorded at 114/74 mmHg, showing no significant changes. These developments raised concerns about potential complications related to the cerclage or underlying cervical changes.

A repeat ultrasound was conducted to closely examine the integrity of the cerclage and the cervix. The imaging revealed a slight increase in cervical dilation to 2.5 cm, with persistent funnelling and increased edema around the cerclage site. No signs of infection or amniotic fluid leakage were detected, but the findings suggested an increased risk of cerclage failure or preterm labor. The laboratory tests showed a stable white blood cell count of 10,600/mm³ and a CRP level of 16 mg/L, indicating no significant inflammatory response. However, the presence of bloody discharge and increased cervical dilation necessitated a reassessment of the current management plan.

Given these findings, the healthcare team deliberated on the best course of action to mitigate the potential risk of preterm birth. They decided to admit the patient for closer observation and initiated a regimen of tocolytics to manage uterine irritability, along with a course of antenatal corticosteroids to enhance fetal lung maturity in case of early delivery. The patient was counseled on the importance of bed rest and was instructed to immediately report any further changes in symptoms. The team planned a comprehensive evaluation in 48 hours to determine the effectiveness of these interventions and to decide on any additional measures needed to support the pregnancy.