Nursing Clinical Practice Guide
Clinical Scenario: You are the nurse admitting Lisa, a 28-year-old G2P1 at 28 weeks gestation, via the Emergency Department. She presents with a high fever (39.0°C/102.2°F), severe right flank pain, nausea, and costovertebral angle (CVA) tenderness. A urinalysis and culture are pending, but she is diagnosed with suspected acute pyelonephritis and admitted for IV antibiotics and monitoring.
Nursing Intervention Strategy:1. Immediate Assessment & Monitoring (Priority):
• Place on a Tocodynamometer (toco) for continuous monitoring of uterine activity. Palpate the uterus frequently for contractions.
• Apply continuous Fetal heart rate (FHR) monitoring. Maternal fever can cause fetal tachycardia.
• Assess vital signs frequently (every 1-2 hours initially) for signs of sepsis: fever, tachycardia, tachypnea, hypotension.
• Perform a focused assessment: pain location/character, urinary output (may need Foley catheter for accurate I&O if nauseated), and cervical status (if ordered by MD/CNM).2. Medical Orders & Collaborative Care:
• Administer IV antibiotics STAT as ordered (e.g., ceftriaxone). Ensure timely doses to maintain therapeutic levels.
• Initiate IV hydration with normal saline or lactated Ringer's to correct dehydration from fever and promote diuresis.
• Administer antipyretics (e.g., acetaminophen) as ordered to reduce fever, which benefits both mother and fetus.3. Supportive Care & Education:
• Manage pain with prescribed analgesics safe in pregnancy.
• Encourage oral fluids aggressively once nausea is controlled (aim for 3-4 L/day).
• Educate the client and family on the signs of preterm labor (regular contractions, pelvic pressure, low backache, change in vaginal discharge) and when to call the nurse immediately.
Patient Safety and Precautions:
• Contraindication: Do not administer any tocolytics (labor-stopping drugs) prophylactically without clear signs of preterm labor and an MD order. Their use is controversial in the setting of infection.
• Medication Caution: Verify the safety of all prescribed medications in pregnancy. Avoid NSAIDs for fever/pain in the third trimester due to risk of premature closure of the fetal ductus arteriosus.
• Key Monitoring: Strict Intake and Output (I&O). Sudden decrease in output could indicate worsening renal function or dehydration.
Nursing Procedure & Medication Flow
Procedure: Initiating Continuous Fetal & Uterine Monitoring
1. Explain the procedure to the client.
2. Place the client in a semi-Fowler's or left lateral tilt position for comfort and optimal perfusion.
3. Locate the fetal back for the best Doppler signal and apply the ultrasound transducer.
4. Place the tocodynamometer on the fundus of the uterus.
5. Adjust belts and monitor settings until a clear FHR tracing and uterine activity line are obtained.
6. Document baseline FHR, variability, presence of accelerations/decels, and any uterine contractions.
Medication: Administering IV Ceftriaxone
• Action: Bactericidal antibiotic; inhibits cell wall synthesis.
• Pregnancy Category: B (Generally considered safe).
• Dilution/Administration: Often reconstituted with 1% Lidocaine for IM injection to reduce pain, but for IV, dilute in 50-100 mL of compatible fluid (e.g., NS). Infuse over 30 minutes.
• Nursing Considerations: Monitor for allergic reaction. Assess IV site for phlebitis. Can cause diarrhea—monitor for Clostridioides difficile (C. diff) infection.
A Word from Your Senior Nurse
"In the whirlwind of admitting a sick pregnant patient, it's easy to get focused on the fever, the pain, and the antibiotics. But your most critical role is being the guardian of that pregnancy. That toco monitor isn't just a machine; it's your early warning system. A subtle increase in uterine irritability or a pattern of regular contractions is your cue to act fast and notify the provider. Catching preterm labor early can mean the difference between delivering a 28-week preemie and successfully suppressing labor to gain those precious extra weeks for fetal lung maturity. Always think: Mother + Baby + Uterus. That's the obstetric nursing trifecta."