A nurse is assisting in evaluating a client's progress during labor.

Exhibits

Click to highlight the client findings that indicate the labor is progressing as expected. To deselect a finding, click on the finding again.

Nurses' Notes

1615:

Client is in the partial sitting position and is instructed to bear down during uterine contraction. Client reports the urge to defecate. There is increased bloody show and the cervix is 10 cm dilated. Contractions 5 min apart. Contractions strong on palpation.

Vital Signs

1615:

Temperature 39.1° C (102.4" F)

Respiratory rate 20/min

Heart rate 110/min

Blood pressure 100/74 mm Hg

Oxygen saturation 96%

• Rheumatoid arthritis is the most likely condition given the client’s bilateral wrist and shoulder stiffness lasting for several hours in the morning, fatigue, and loss of appetite. The elevated ESR and anemia further support chronic inflammation. Positive ANA, while not specific, can be present in RA and other autoimmune disorders.
• Osteoarthritis is incorrect because it typically presents with stiffness that improves within 30 minutes of activity, not lasting for several hours. It is also a non-inflammatory condition, whereas the client has elevated ESR and anemia, suggesting an inflammatory process.
• Gout is unlikely as it usually causes acute, severe joint pain with redness and swelling, often affecting the big toe. The client’s uric acid level is within normal range, making gout less probable.
• Carpal tunnel syndrome primarily causes numbness, tingling, and weakness in the hands due to median nerve compression. It does not typically cause prolonged morning stiffness, fatigue, or systemic inflammation.
• Positive ANA is not the best choice because while it is seen in rheumatoid arthritis, it is also present in other autoimmune diseases such as lupus. It does not specifically confirm RA.
• Normal WBC count does not support an inflammatory condition, as RA can lead to mild leukopenia, which is seen in the follow-up labs.
• Low blood pressure is not a defining feature of RA and does not correlate with the client’s symptoms or disease progression

Rationale for Correct Choices:

Chorioamnionitis is a bacterial infection of the amniotic fluid and fetal membranes, which can develop when the protective barrier is compromised due to prolonged rupture of membranes. This client reported clear fluid discharge the previous evening, indicating that the membranes have been ruptured for an extended period. The risk of infection increases significantly as time progresses. Additionally, the client exhibits signs of maternal restlessness and increased fetal heart rate, which could indicate an early response to infection or fetal distress.

Hemorrhage is a significant risk during labor, especially as the cervix approaches full dilation and the client exhibits increasing amounts of blood-tinged vaginal discharge. The client’s history of previous pregnancy loss and current cervical changes suggest that monitoring for postpartum hemorrhage will be essential, particularly after delivery.

Rationale for Incorrect Choices:

Disseminated intravascular coagulopathy is a severe complication associated with conditions such as placental abruption, preeclampsia, or amniotic fluid embolism. However, this client does not exhibit hallmark signs such as widespread bruising, uncontrolled bleeding, or abnormal clotting, making this a less likely immediate risk.

Seizures are characteristic of eclampsia, which is typically preceded by severe preeclampsia. While the client is restless and experiencing significant pain, there are no findings of hypertension, hyperreflexia, or neurological disturbances such as visual changes or altered mental status, making seizures an unlikely concern at this time.

Preeclampsia is a hypertensive disorder of pregnancy characterized by elevated blood pressure, proteinuria, and systemic symptoms. This client has stable blood pressure readings within the normal range, no evidence of proteinuria, and no indications of significant organ dysfunction, making preeclampsia an unlikely concern.

Dehydration is a potential concern due to the client’s nausea, vomiting, and lack of recent oral intake. However, there are no immediate signs of hemodynamic instability, such as hypotension or tachycardia, suggesting that dehydration is not the most pressing concern at this moment.