A nurse is caring for a client in labor who has an epidural in place and is on continuous internal monitoring with a fetal scalp electrode and intrauterine pressure catheter.

The nurse notes a strong contraction on the monitor and the client reports nausea accompanied by an urgent need to have a bowel movement.

Which of the following assessments is the nurse's highest priority?

Choice A rationale

Increased leukorrhea, or vaginal discharge, is a common and normal physiological finding during pregnancy due to increased estrogen levels and blood flow to the vaginal area. This increase in discharge helps prevent ascending infections. Unless accompanied by itching, odor, or color changes, it typically does not indicate a problem.

Choice B rationale

Urinary frequency is a common symptom in late pregnancy, particularly in the third trimester. It results from the enlarging uterus compressing the bladder, reducing its capacity, and increasing renal blood flow and glomerular filtration rate, leading to increased urine production. It is a normal physiological adaptation.

Choice C rationale

A persistent headache in a pregnant client, especially in the third trimester, is a priority to assess further because it can be a sign of preeclampsia, a serious hypertensive disorder of pregnancy. Other symptoms of preeclampsia include visual disturbances, right upper quadrant pain, and proteinuria. Early identification is crucial for intervention.

Choice D rationale

Insomnia is a common complaint during the third trimester of pregnancy. It can be attributed to various factors such as physical discomfort, frequent urination, fetal movements, anxiety, and hormonal changes. While bothersome, it is generally considered a normal, though often challenging, aspect of late pregnancy.

1. Administer magnesium sulfate bolus: Anticipated. Magnesium sulfate is the drug of choice to prevent seizures in severe preeclampsia or eclampsia. The client shows signs of severe preeclampsia (hypertension, headache, visual disturbances, hyperreflexia, clonus, epigastric pain), so a magnesium sulfate bolus is appropriate to reduce CNS irritability and prevent eclamptic seizures.
2. Insert an indwelling urinary catheter: Anticipated. Monitoring urine output is essential in hypertensive disorders of pregnancy to assess kidney function and fluid balance. The client’s urine output (25–55 mL/hr) is borderline low (normal >30 mL/hr), so catheter insertion allows accurate measurement.
3. Initiate intravenous (IV) fluids: Contraindicated. In preeclampsia, patients often have intravascular volume depletion with risk of pulmonary edema due to increased capillary permeability. IV fluids should be carefully restricted to avoid fluid overload, so routine IV fluid initiation is contraindicated unless hypovolemia or dehydration is confirmed.
4. Administer nifedipine 30 mg intermittent IV bolus: Contraindicated. Nifedipine, a calcium channel blocker, is given orally for hypertension in pregnancy, but intermittent IV bolus administration is not recommended because it can cause abrupt hypotension and fetal distress.
5. Begin intermittent electronic fetal monitoring: Anticipated. Continuous or intermittent fetal monitoring is critical for detecting fetal distress, especially in high-risk pregnancies with maternal hypertension and irregular contractions, ensuring timely intervention if needed.