Urinary Tract Infection (Acute Cystitis and Acute Pyelonephritis)
A pregnant client at 28 weeks gestation is diagnosed with acute pyelonephritis. Which nursing intervention should be the priority?
A 28-year-old pregnant woman at 28 weeks gestation presents to the emergency department with complaints of fever, chills, flank pain, and dysuria. Her vital signs are: temperature 101.8°F (38.8°C), pulse 110 bpm, respirations 22/min, and blood pressure 100/60 mmHg. Laboratory results show elevated white blood cell count and positive urine culture. The physician diagnoses acute pyelonephritis and orders IV antibiotic therapy.
1Encourage increased oral fluid intake to 3-4 liters per day
2Position the client in Trendelenburg position to improve renal perfusion
3Monitor for signs and symptoms of preterm labor✓ 정답
4Apply heat to the flank area to reduce pain and promote comfort
해설
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 ExplanationKey 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 GuideClinical 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:
1Assessment & 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).
2Infection ManagementAdminister 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.
3Comfort & SupportPosition 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:
1Medication SafetyVerify 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.
2Septic ShockBe 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 FlowIV 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."
Acute Pyelonephritis — A bacterial infection of the renal pelvis and parenchyma. In pregnancy, it is a serious condition due to physiological hydronephrosis and immunosuppression, leading to high risks of sepsis and preterm labor.
Preterm Labor — Regular uterine contractions resulting in cervical change occurring before 37 weeks of gestation. Infections like pyelonephritis are a major trigger due to inflammatory mediator release.
Tocodynamometer — The external component of a fetal monitor placed on the maternal abdomen to detect and record uterine contractions.
Left Lateral Recumbent Position — Positioning a pregnant woman on her left side. This displaces the uterus off the inferior vena cava and aorta, improving venous return, cardiac output, and uteroplacental/renal perfusion.
Urosepsis — Sepsis originating from a urinary tract infection. It is a life-threatening organ dysfunction caused by a dysregulated host response to infection and a critical complication of pyelonephritis.