A client arrives in labor and delivery, and the L&D primary nurse gets a report from the L&D triage nurse.
How does the primary nurse interpret the following information on the client's labor: 2 cm, 60%, and -2 station?

 

Rationale for correct condition: The client is likely experiencing PPROM, as evidenced by the sudden gush of clear fluid and continued light leakage, confirmed by fluid pooling in the vaginal vault that tested positive for ferning. PPROM can lead to preterm labor and increased risk of infection. The absence of contractions or bleeding, and the mild lower abdominal discomfort, further supports this diagnosis.

Rationale for actions: Administering prophylactic antibiotics helps prevent infection, which is a significant risk with PPROM. Educating the client on kick counts ensures monitoring of fetal well-being. Preparing for an emergent C-section is not immediately necessary as the cervix is closed. Providing IV fluids for hypotension is not applicable here as blood pressure is elevated. Discharging the client with follow-up in one week is inappropriate given the risk of infection and preterm labor.

Rationale for parameters: Monitoring signs of infection is crucial, as PPROM increases infection risk. Maternal blood pressure trends must be watched due to elevated readings, suggesting possible complications. Meconium-stained amniotic fluid, while concerning, is not present. Maternal platelet levels and fundal height measurements do not directly address the current risks associated with PPROM.

Rationale for incorrect conditions: Placental abruption typically involves abdominal pain and bleeding, which are absent. Preeclampsia involves hypertension and proteinuria, but no significant proteinuria is present. Oligohydramnios involves decreased amniotic fluid, but the client reports clear fluid leakage indicating rupture of membranes.

Choice A rationale

Left occiput anterior (LOA) describes the occiput facing toward the front left of the maternal pelvis, not the back. LOA typically does not cause back labor.

Choice B rationale

Right occiput posterior (ROP) describes the occiput facing toward the back right of the maternal pelvis, not the left. ROP can cause back labor but is not aligned with the described position.

Choice C rationale

Left occiput posterior (LOP) means the occiput is facing the back left of the maternal pelvis, aligning with the description and commonly causing back labor pain.

Choice D rationale

Right occiput anterior (ROA) describes the occiput facing the front right of the maternal pelvis, not the left. ROA is not associated with increased back labor pain. .