A nurse is caring for a client who is in active labor. The nurse should notify the provider for which of the following findings?

A. Blood pressure. A blood pressure of 162/112 mm Hg is severely elevated and indicative of preeclampsia, a serious complication during pregnancy. Uncontrolled hypertension can lead to maternal and fetal complications, such as eclampsia, placental abruption, or fetal growth restriction.

B. Urine ketones. The absence of ketones in the urine is normal and does not indicate any prenatal complication. Ketones would typically be seen in cases of starvation, dehydration, or poorly controlled diabetes, which are not evident here.

C. Urine protein. The presence of 3+ protein in the urine is a key diagnostic marker for preeclampsia. This finding, combined with elevated blood pressure, signals potential damage to the kidneys, which is a hallmark of severe preeclampsia.

D. Report of headache. A severe headache unrelieved by acetaminophen is a concerning symptom of preeclampsia. It suggests potential central nervous system involvement, which could lead to complications like seizures if left untreated.

E. Respiratory rate. The client’s respiratory rate of 16/min is within the normal range and does not indicate any immediate concern related to her pregnancy or current condition.

F. Fetal activity. The client’s report of decreased fetal movement is concerning and may indicate fetal distress or compromised placental function. This finding requires prompt evaluation to ensure fetal well-being.

Nurses' Notes

0900:

Client who is at 38 weeks of gestation presents to the antepartum unit with uterine contractions, dark red vaginal bleeding, and abdominal pain that started approximately 45 min prior to arrival. Rates abdominal pain a 7 on a scale of 0 to 10. Client reports, "My blood pressure has been high during the pregnancy."

Home Medications: prenatal multivitamin, methyldopa 250 mg PO twice daily Physical Exam:

General: tearful, anxious

Cardiovascular: S1, S2, no murmur

Respiratory: bilateral breath sounds clear

Abdomen: Uterine hypertonicity with a board-like abdomen, tenderness noted upon palpation of left upper quadrant

FHR: 116/min, minimal variability noted

Rationale:

Dark red vaginal bleeding: This could indicate a serious complication such as placental abruption, which can lead to fetal and maternal distress. Dark red bleeding is often associated with this condition and requires immediate follow-up to determine the source and to prevent further complications.

Uterine hypertonicity with a board-like abdomen: Uterine hypertonicity and a "board-like" abdomen may suggest uterine contractions that are intense or sustained, which could be associated with placental abruption or other serious obstetric complications. This finding needs follow-up to assess for uterine rupture, abruption, or other causes of uterine distress.

Pain score of 7/10: The client's moderate-to-severe pain (rated 7/10) requires follow-up to manage pain and evaluate for its cause. Pain related to placental abruption or other complications may be severe and should be managed appropriately.

FHR of 116/min with minimal variability: A fetal heart rate (FHR) of 116/min is within the normal range, but minimal variability could suggest fetal distress or compromise. Follow-up is needed to continuously monitor fetal well-being and assess for any changes in FHR patterns.