A pregnant client at 28 weeks gestation is admitted with acu… | 마이메르시 MyMerci
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문제

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

해설
Monitoring for preterm labor is the priority because pyelonephritis in pregnancy increases preterm labor risk due to inflammatory response. Other interventions are supportive but secondary.

심화 해설

Core Nursing Explanation Key Concept Analysis: This question tests the priority nursing intervention for a pregnant patient with Acute pyelonephritis. The core theme is recognizing that infection, especially in the urinary tract, is a significant trigger for Preterm labor in pregnancy. The pathophysiology involves the systemic inflammatory response to the infection, which releases prostaglandins and cytokines that can stimulate uterine contractions and cervical changes.

Answer Rationale: Key Point! In pregnancy, the priority concern with any significant infection, particularly pyelonephritis, is the prevention and early detection of preterm labor. Pyelonephritis is a leading cause of hospitalization in pregnancy and a known risk factor for preterm birth. Therefore, the nurse's primary action is continuous monitoring for uterine activity (contractions), cervical changes, and other signs of labor. This aligns with the nursing process principle of prioritizing potential life-threatening complications.

Distractor Analysis:
• Watch out for confusion! Option ①: While increasing fluid intake is a standard and important intervention for pyelonephritis to flush the urinary tract, it is a supportive measure, not the immediate priority for a pregnant patient upon admission. The risk of preterm labor supersedes this.
• Option ②: Administering antiemetics addresses a symptom (nausea/vomiting) which may be present, but it does not address the primary, life-altering risk to the pregnancy (preterm birth). Symptom management is secondary to complication monitoring.
• Option ④: Positioning in Left lateral recumbent position is beneficial for improving placental blood flow in pregnancy, but it is a general comfort and circulatory measure, not the specific, urgent priority related to the admitting diagnosis of pyelonephritis.

Related Concepts: The nurse must also monitor for signs of Sepsis (fever, tachycardia, hypotension), which can accompany pyelonephritis and further threaten the fetus. Administration of IV antibiotics is a critical medical intervention, and the nurse ensures timely administration while monitoring for therapeutic effect and side effects.

Concept Summary • Patho Link: Infection → Inflammatory Response → Prostaglandin Release → Uterine Irritability → Preterm Labor.
• Nursing Priority (ABCs with a twist): In obstetric nursing, think "ABC + Uterus". After Airway, Breathing, Circulation, assess the Uterus (contractions, fetal heart tones).
• Key Monitoring: Contraction frequency/duration, cervical status, fetal heart rate (FHR), maternal vital signs (especially temperature), and signs of sepsis.

Side-by-Side Comparison!
Condition in PregnancyPrimary Maternal RiskPrimary Fetal/Obstetric RiskKey Nursing Priority
Acute PyelonephritisSepsis, Renal impairmentPreterm Labor & BirthMonitor for uterine contractions & preterm labor
PreeclampsiaSeizures (Eclampsia), Stroke, HELLP syndromePlacental abruption, Fetal growth restrictionMonitor BP, neuro status, for seizures; administer MgSO₄
Gestational DiabetesHypo/Hyperglycemia, future Type 2 DMMacrosomia, Birth injury, Neonatal hypoglycemiaMonitor blood glucose; educate on diet & insulin

Anatomy, Physiology & Pharmacology Points • Physiology: Progesterone causes ureteral dilation and urinary stasis in pregnancy, predisposing to ascending UTIs that can lead to pyelonephritis.
• Pharmacology: First-line IV antibiotics for pyelonephritis in pregnancy are often cephalosporins (e.g., ceftriaxone) or penicillins. Avoid fluoroquinolones and tetracyclines due to fetal risks.

Memory Tips • Acronym: P.I.E. for Pyelonephritis In Pregnancy: Preterm labor monitor, IV antibiotics & fluids, Evaluate for sepsis.
• Association: Think of the uterus as an "angry neighbor" to the infected kidneys. The inflammation can easily "wake up" the uterus and start contractions.

High-Frequency NCLEX Topics NCLEX loves to test priority-setting in obstetric complications. Pyelonephritis in pregnancy is a classic scenario. Remember: In any pregnant patient with an infection, trauma, or acute illness, always ask yourself: "What is the risk to the pregnancy?" The answer often involves preterm labor, fetal well-being, or specific conditions like preeclampsia.

Watch Out for Question Variations! • Instead of asking for the priority intervention, the question might ask: "The nurse should monitor the client for which most serious complication?" Answer: Preterm labor.
• The scenario could change the gestational age: At 28 weeks, the priority is preventing preterm birth. If the client were at 38 weeks, the focus might shift more to preparing for possible induction or managing sepsis, but uterine monitoring remains critical.
• It could be combined with a symptom: "Client has a temperature of 39.5°C (103.1°F) and chills." The priority is still monitoring for labor and initiating fever management/cooling measures to reduce fetal tachycardia and maternal discomfort.

임상 시나리오

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."

핵심 개념

  • Acute Pyelonephritis — A severe infection of the renal pelvis and parenchyma, often ascending from a lower UTI. In pregnancy, it is a medical emergency due to high risk of sepsis and preterm labor.
  • Preterm Labor — Regular uterine contractions resulting in cervical change occurring after 20 weeks and before 37 weeks of gestation. A major complication associated with maternal infection.
  • Left Lateral Recumbent Position — A position in which the pregnant client lies on her left side. This position displaces the uterus off the inferior vena cava, improving venous return and placental blood flow.
  • Tocodynamometer — An external monitor placed on the maternal abdomen to measure and record the frequency and duration of uterine contractions.
  • Sepsis — A life-threatening organ dysfunction caused by a dysregulated host response to infection. A potential complication of untreated pyelonephritis.

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