A nurse is admitting an adolescent who has rubella.

Which of the following actions should the nurse take?

The nurse should recognize the client is experiencing preterm labor due to previous preterm birth.

Preterm labor is when regular contractions begin to open the cervix before 37 weeks of pregnancy. One of the risk factors for preterm labor is having a previous preterm delivery. The client’s history indicates that her last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks gestation. The client’s current symptoms, such as lower back pain, pinkish vaginal discharge, uterine contractions and cervical dilation, also suggest that she is in preterm labor. Therefore, the nurse should recognize that the client is experiencing preterm labor due to previous preterm birth.

BMI, blood type and blood pressure are not causes of preterm labor in this case. BMI may be associated with preterm labor if it is too high or too low, but the client’s BMI is within the normal range for pregnancy. Blood type may cause Rh incompatibility if the mother is Rh negative and the baby is Rh positive, but the client’s blood type is Rh positive. Blood pressure may cause preeclampsia if it is too high, but the client’s blood pressure is normal. Abruptio placentae is a condition where the placenta separates from the uterine wall before delivery, which can cause vaginal bleeding, abdominal pain and fetal distress. The client does not have these signs.

• B: Heart rate 99/min. This is a finding that requires immediate follow-up because it is above the normal range for a 16-year-old client, which is 60 to 100 beats per minute. A high heart rate could indicate anxiety, stress, pain, infection or other conditions that need to be addressed.

• D: Client experiences nightmares. This is a finding that requires immediate follow-up because it could indicate post-traumatic stress disorder (PTSD), which is a mental health condition that can develop after witnessing or experiencing a traumatic event. PTSD can cause distressing symptoms such as nightmares, flashbacks, intrusive thoughts, avoidance, negative mood and hyperarousal. PTSD can interfere with the client’s daily functioning and well-being and requires professional treatment.

• E: Witnessing their family’s death. This is a finding that requires immediate follow-up because it is the most likely cause of the client’s PTSD symptoms and emotional distress. Witnessing the death of one’s family members is a devastating and traumatic experience that can have lasting effects on the client’s mental health. The client may benefit from grief counseling, trauma-focused therapy, medication or other interventions to help them cope with their loss and trauma.

• H: Smoking marijuana to clear their mind. This is a finding that requires immediate follow-up because it indicates that the client is using an illicit substance to self-medicate their emotional pain. Smoking marijuana can have negative effects on the client’s physical and mental health, such as impairing their memory, cognition, judgment, coordination and motivation. It can also increase the risk of addiction, dependence and withdrawal symptoms. The client may need substance abuse counseling, education, referral or other services to help them quit smoking marijuana and find healthier ways to cope with their feelings.
The other findings do not require immediate follow-up for the following reasons:

• A: BP 122/80 mmHg. This is not a finding that requires immediate follow-up because it is within the normal range for a 16-year-old client, which is 110 to 120/70 to 80 mmHg. A normal blood pressure indicates that the client’s cardiovascular system is functioning well and there are no signs of hypertension or hypotension.

• C: Startles easy during thunderstorm. This is not a finding that requires immediate follow-up because it is a normal reaction to a loud noise or a frightening stimulus. The client admits that they have always been afraid of thunderstorms, which suggests that this is not a new or unusual behavior for them. However, the nurse may want to monitor the client’s anxiety level and provide reassurance and comfort during thunderstorms.

• F: Caregiver reporting client acting differently than usual. This is not a finding that requires immediate follow-up because it is a vague and subjective statement that does not specify how the client is acting differently or what changes have occurred in their behavior. The nurse may want to ask the caregiver for more details and examples of how the client has changed since the traumatic event and assess whether these changes are normal or concerning.

• G: Attends school regularly. This is not a finding that requires immediate follow-up because it indicates that the client is maintaining their academic performance and social interactions despite their trauma and grief. Attending school regularly can provide the client with a sense of routine, structure, support and achievement that can help them cope with their situation. However, the nurse may want to check with the client’s teachers and peers to see if they have noticed any changes in the client’s mood, behavior or participation at school.