A pregnant client at 28 weeks gestation is diagnosed with acute pyelonephritis. Which nursing intervention should be the priority?

Acute pyelonephritis during pregnancy increases preterm labor risk due to inflammatory prostaglandin release, making monitoring for contractions and cervical changes the priority. Other options are supportive but not emergent.

Core Nursing Explanation Key Concept Analysis: This question assesses the nurse's ability to prioritize care for a pregnant patient with a serious infection. The core theme is recognizing that acute pyelonephritis in pregnancy is a medical emergency due to its high risk of triggering preterm labor. The pathophysiology involves the systemic inflammatory response and the release of prostaglandins from the infected renal tissue, which can stimulate uterine contractions. The priority shifts from simply treating the infection to also protecting the pregnancy.

Answer Rationale: Key Point! Option ③ is correct because monitoring for preterm labor is the highest priority nursing intervention. The patient is at 28 weeks gestation, which is pre-viable or at the edge of viability. Preventing preterm birth is critical for fetal outcomes. The nurse must continuously assess for uterine contractions, changes in cervical status, rupture of membranes, and any vaginal bleeding. This intervention directly addresses the most serious and immediate threat to the fetus.

Distractor Analysis:
Watch out for confusion! Option ① (Encourage fluids) is a supportive measure to flush the urinary tract and maintain hydration, but it is not the priority in this acute, febrile, and potentially septic presentation. IV fluids are typically initiated first.
Option ② (Trendelenburg position) is incorrect and potentially harmful. The Trendelenburg position (head down, feet up) is not indicated for improving renal perfusion in pyelonephritis. It can increase intracranial pressure and respiratory difficulty and is not a standard intervention for this condition.
Option ④ (Apply heat) is a comfort measure that may be implemented, but it does not address the life-threatening risks of sepsis or preterm labor. Pain management is important but secondary to surveillance for maternal and fetal complications.

Related Concepts: The management of acute pyelonephritis in pregnancy requires a dual focus: aggressive treatment of the infection (IV antibiotics, hydration, antipyretics) and vigilant obstetric monitoring. Sepsis is another major maternal risk. Understanding the link between infection, inflammation, prostaglandins, and uterine activity is crucial for maternal-child nursing.

Nursing Clinical Practice Guide Clinical Scenario: You are the nurse admitting a 28-week pregnant patient, Ms. Jones, with a diagnosis of acute pyelonephritis. She is anxious, febrile, and in pain.

Nursing Intervention Strategy: 1. Assessment & Monitoring (Priority): Immediately place the patient on a tocodynamometer (toco) for continuous electronic fetal monitoring (EFM) to assess for uterine contractions and fetal heart rate (FHR). Assess for signs of preterm labor: palpable uterine tightening, cramping, low backache, pelvic pressure, or increased vaginal discharge. Monitor vital signs frequently (every 1-2 hours initially) for signs of worsening infection or sepsis (e.g., tachycardia, hypotension, fever). 2. Infection Management: Administer IV antibiotics as ordered (commonly cephalosporins like ceftriaxone). Ensure timely administration to maintain therapeutic levels. Administer IV fluids to correct dehydration and promote renal flushing. Administer antipyretics (e.g., acetaminophen) for fever to improve maternal comfort and reduce fetal stress. 3. Comfort & Support: Position the patient in a left lateral recumbent position to optimize uteroplacental blood flow and renal perfusion. Offer a warm pack (not excessively hot) to the flank for comfort, as per option ④, after priority assessments are done. Provide emotional support and education about her condition.

Patient Safety and Precautions: - Medication Safety: Verify all medications are safe for pregnancy. Avoid NSAIDs (e.g., ibuprofen) in the third trimester due to the risk of premature closure of the fetal ductus arteriosus. - Septic Shock: Be vigilant for signs of urosepsis: temperature > 101.3°F (38.5°C) or < 96.8°F (36°C), heart rate > 90 bpm, respiratory rate > 20/min, altered mental status.

Nursing Procedure & Medication Flow IV Antibiotic Administration in Pregnancy: 1. Confirm the drug is pregnancy Category B (e.g., most cephalosporins, penicillins). 2. Check for allergies (especially penicillin/cephalosporin cross-reactivity). 3. Administer the dose on time to maintain bactericidal levels. 4. Monitor for effectiveness (decreased fever, pain, WBC count) and side effects (rash, diarrhea). 5. After IV therapy, the patient will often be switched to an oral antibiotic to complete a 10-14 day course.

A Word from Your Senior Nurse "In obstetrics, we always think for two. A fever and infection in mom isn't just about her—it's a direct threat to the baby's home. Your first job with this pyelo patient isn't just to hang the antibiotic; it's to put on that fetal monitor and watch that strip like a hawk. Catching early contractions can mean the difference between stopping preterm labor and a neonatal ICU admission. Remember: Monitor the mom, protect the baby. This integrated thinking is what makes a great OB nurse and is absolutely tested on the NCLEX."