A nurse is caring for a client at a clinic.

Exhibits

Complete the following sentence by using the lists of options. The client is at risk for developing

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due to

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A. The nurse should begin by donning sterile gloves to maintain a sterile field.
B. The suction machine should be turned on, and the pressure should be set before starting the suctioning.
C. The catheter should be inserted during the client’s inspiration to minimize discomfort and maximize
effectiveness.
D. Suction should be applied while rotating the catheter to prevent tissue damage and to clear secretions effectively.
E. After suctioning, the catheter should be rinsed to remove any remaining secretions.

Rationale
1. History and Physical
Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks
The client's history of a preterm birth at 30 weeks in a previous pregnancy is a significant risk factor for preterm labor in the current pregnancy. A history of preterm labor increases the likelihood of recurrence, and close monitoring is essential. This information alone does not require immediate follow- up but is important in guiding the overall care plan and risk assessment for preterm labor.
2. Nurses' Notes
Lower back pain and pinkish vaginal discharge.
Lower back pain and pinkish vaginal discharge are common symptoms of preterm labor. The pinkish vaginal discharge could indicate bloody show, which is sometimes seen with cervical dilation or preterm labor.
Uterine contractions every 8 minutes, palpate strong, duration 30 seconds.
Regular uterine contractions (every 8 minutes) in a client at 33 weeks gestation could indicate preterm labor. Contractions every 8 minutes with strong palpation and 30-second duration should be further assessed for their frequency, intensity, and impact on cervical dilation. This finding requires follow-up to determine whether these contractions are progressing to actual labor.
Minimal variability.
Minimal variability can sometimes be a sign of fetal distress or hypoxia, but it can also be seen in some normal circumstances. However, it is a finding that requires closer observation and may warrant further investigation to assess fetal well-being, especially in the context of preterm labor.
Finding: Cervical exam indicates 2 cm, 50% effaced, 0 station.
The cervix is 2 cm dilated, 50% effaced, and at a station of 0. This indicates that the cervix is beginning to open and efface, which is a sign of early labor. Since the client is at 33 weeks gestation, this is concerning for preterm labor, and the client should be closely monitored for further cervical changes and labor progression.