A nurse is caring for a female client who is at 30 weeks of gestation in the labor and delivery unit.

Exhibits

The nurse is reviewing the client's assessment data. For each assessment finding below, click to specify if the finding is consistent with placenta previa, preterm labor, or abruptio placenta. Each finding may be consistent with more than one condition

Choice A rationale

Oxygen is typically administered for fetal distress or maternal hypoxemia, not routinely for pain management or epidural preparation. The priority before an epidural is often to stabilize maternal blood pressure, as the procedure frequently causes vasodilation and subsequent hypotension due to sympathetic blockade.

Choice B rationale

A key side effect of epidural anesthesia is hypotension caused by peripheral vasodilation from sympathetic nerve blockade. Administering a pre-procedure intravenous (IV) fluid bolus (e.g., normal saline or lactated Ringer's) increases circulating blood volume, effectively helping to minimize the risk and severity of this common hemodynamic change.

Choice C rationale

Ondansetron is a serotonin antagonist primarily used to treat nausea and vomiting. While sometimes used for these side effects in labor, it is not the priority action before an epidural. Fluid administration to prevent hypotension is the critical immediate prophylactic measure required for maternal safety.

Choice D rationale

While epidurals are commonly placed in the active phase of labor (usually 4 to 5 cm dilation or more), delaying the procedure until 7 cm is an outdated and arbitrary practice. The timing is determined by maternal request, pain level, and clinical assessment, not a rigid cervical dilation number, as effective pain relief is crucial.

The nurse should first address the fetal heart rate followed by the client's vaginal discharge.

WBC count rationale: A WBC count of 22,000/mm³ is significantly elevated above the normal range of 5,000 to 10,000/mm³, suggesting maternal infection such as chorioamnionitis. While this is clinically important, it is not the immediate first priority in acute obstetric care. Maternal infection must be managed, but fetal well-being is prioritized first because hypoxia or distress can occur rapidly and requires immediate recognition and intervention before laboratory abnormalities are addressed.

Maternal Blood Type rationale: The maternal blood type of O negative is clinically relevant for Rh incompatibility and the need for Rho(D) immune globulin administration. However, this is not an acute priority in the setting of preterm labor with rupture of membranes. Blood type considerations are important for long-term management but do not supersede the need to assess fetal well-being or evaluate vaginal discharge for evidence of amniotic fluid leakage or bleeding.

Fetal heart rate rationale: Fetal heart rate monitoring is the highest priority because it provides real-time information about fetal oxygenation and well-being. The normal baseline range is 110 to 160 beats per minute, and this client’s rate of 148/min is within normal limits. However, continuous monitoring is essential due to preterm labor, rupture of membranes, and maternal fever, all of which increase the risk of fetal distress. Therefore, fetal heart rate assessment is addressed first to ensure immediate recognition of hypoxia or compromise.

Respiratory rate rationale: The maternal respiratory rate of 18/min is within the normal adult range of 12 to 20/min. This finding does not indicate acute compromise and does not require urgent intervention. While maternal respiratory status is always monitored, it is not prioritized above fetal assessment or evaluation of vaginal discharge in this scenario. Thus, respiratory rate is stable and requires only routine monitoring, not immediate follow-up in the prioritization of care.

Blood pressure rationale: The maternal blood pressure of 112/59 mm Hg is within acceptable limits for pregnancy, as mild decreases in systemic vascular resistance are physiologic. Hypotension would be concerning if systolic <90 mm Hg or diastolic <50 mm Hg, but this value does not indicate shock or preeclampsia. Therefore, blood pressure is not prioritized over fetal monitoring or vaginal discharge assessment in this case. It remains stable and requires routine monitoring only.

Vaginal discharge rationale: Vaginal discharge is the next priority after fetal heart rate because the client has clear fluid with nitrazine positive, confirming premature rupture of membranes, along with mucous discharge and bleeding. These findings raise concern for infection, preterm labor progression, and placental complications. Evaluating vaginal discharge helps determine the presence of amniotic fluid, blood, or purulent material, guiding urgent interventions. Therefore, it is addressed immediately after fetal heart rate monitoring to prevent maternal and fetal complications.