A pregnant client at 20 weeks gestation is diagnosed with cervical incompetence and is scheduled for cervical cerclage placement. Which nursing intervention is the priority in the preoperative period?
1Assess for signs of preterm labor and uterine contractions✓ 정답
2Administer prophylactic antibiotics as ordered
3Obtain informed consent from the client
4Position the client in Trendelenburg position
해설
Assessing for signs of preterm labor and uterine contractions is the priority because active labor is a contraindication to cervical cerclage. Other interventions are important but secondary to ensuring the procedure can be safely performed.
Core Nursing ExplanationKey Concept Analysis: This question assesses the priority nursing intervention for a client with Cervical incompetence (Insufficient cervix) before a Cervical cerclage procedure. The core theme is patient safety and identifying absolute contraindications to surgery. Cervical incompetence is a painless, passive dilation of the cervix in the second trimester, often leading to pregnancy loss. Cerclage is a surgical stitch placed around the cervix to provide mechanical support. The most critical contraindication for this procedure is the presence of active Preterm labor, as placing a suture on a contracting, dilating cervix can cause cervical laceration, rupture of membranes, or trap the fetus.
Answer Rationale: Key Point! The priority intervention is to Assess for signs of preterm labor and uterine contractions. This assessment directly determines if it is safe to proceed with the surgery. The nurse must confirm the absence of regular contractions, cervical change, rupture of membranes (ROM), vaginal bleeding, or infection before the client goes to the operating room. This aligns with the nursing process where Assessment always comes first to ensure patient safety and guide all subsequent actions.
Distractor Analysis:
Option ② (Administer prophylactic antibiotics): While antibiotics may be ordered to prevent infection, this is a standard preoperative order, not the immediate priority. Administering medications comes after ensuring the procedure is appropriate and safe.
Option ③ (Obtain informed consent): Informed consent is a crucial legal and ethical step. However, the process of consent includes explaining the procedure, risks, and alternatives. Part of that discussion hinges on the client's current condition. If the assessment reveals active labor, the procedure would be canceled, making the consent void. Therefore, assessment logically precedes the finalization of consent.
Option ④ (Position in Trendelenburg): The Trendelenburg position (head down) is sometimes used during the procedure to help displace the uterus and provide better surgical access. It is not a preoperative priority in the client's room and is not indicated for all clients.
Related Concepts: The priority of assessment (especially for contraindications) before any procedure is a fundamental NCLEX principle. Other contraindications for cerclage include active bleeding, chorioamnionitis (intra-amniotic infection), or fetal distress. Postoperatively, monitoring for complications like infection, ROM, or suture displacement is key.
Surgical procedure (McDonald or Shirodkar) to suture the cervix closed. Usually placed at 12-14 weeks, removed at 36-37 weeks or at onset of labor.
Preoperative Priority
Rule out active preterm labor (contractions, cervical change), infection, or bleeding—absolute contraindications.
Postoperative Care
Monitor for signs of infection (fever, foul discharge), preterm labor, and premature rupture of membranes (PROM). Activity restrictions often advised.
Side-by-Side Comparison!
Preterm Labor (Contraindication)
Normal Pre-Cerclage Status
Regular, painful uterine contractions
No or only sporadic Braxton Hicks contractions
Cervical dilation >2-3 cm or effacement
Cervix may be shortened but closed
Possible rupture of membranes (ROM)
Intact membranes
Requires tocolytic therapy, not surgery
Candidate for preventive cerclage
Anatomy, Physiology & Pharmacology Points
Anatomy: The cervix is the lower, narrow part of the uterus that opens into the vagina. Incompetence means it weakens and opens prematurely under the weight of the growing pregnancy.
Physiology: Progesterone helps maintain cervical integrity. Cerclage provides external structural support to compensate for the weak internal os.
Pharmacology: Preoperative antibiotics (e.g., cephalosporins) may be used. Postoperatively, if contractions occur, Tocolytics (e.g., nifedipine, indomethacin) might be administered.
Memory TipsMnemonic: ASSESS Before You STITCH Assess for labor (contractions) Screen for infection (fever, discharge) Secure consent (after assessment) Evaluate for bleeding/ROM Start antibiotics (if ordered)
Then, proceed with the STITCH (cerclage).
High-Frequency NCLEX Topics
This integrates maternal nursing priorities, preoperative safety, and contraindication recognition. NCLEX loves questions where you must choose assessment over action, especially when the action (surgery, medication) could be harmful if the patient's status is not first verified.
Watch Out for Question Variations!
Postoperative Priority: "After cervical cerclage, which finding should the nurse report immediately?" (Answer: Signs of infection or preterm labor).
Patient Education: "What discharge instruction is most important for a client after cerclage?" (Answer: Report signs of infection, contractions, or fluid leakage immediately).
Contraindication Identification: "The nurse knows cerclage is contraindicated for a client with which finding?" (Answer: Regular uterine contractions every 5 minutes).
Nursing Clinical Practice GuideClinical Scenario: You are the nurse on the antenatal unit. Maria, a 24-year-old G2P1 at 20 weeks gestation, is admitted for elective cervical cerclage due to a history of painless second-trimester loss. She reports feeling "some tightening" in her abdomen occasionally.
Nursing Intervention Strategy:
Assessment (Priority): Place the client on the external fetal monitor (tocodynamometer) to assess for uterine contractions. Palpate the uterus for firmness and regularity. Ask specifically about pain, pressure, vaginal discharge (especially clear fluid), or bleeding. Review any home monitoring data.
Communication & Planning: Report findings immediately to the provider. If no contractions are present, proceed with the preoperative checklist. If contractions are present, the provider may order a fetal fibronectin test or cervical length ultrasound and consider administering tocolytics or canceling the procedure.
Preoperative Care: Once cleared, obtain informed consent, ensuring the client understands the procedure, risks (infection, PROM, labor), and that the suture will be removed later. Administer preoperative medications as ordered.
Postoperative Monitoring: After the procedure, continue monitoring for contractions, signs of infection (elevated temperature, foul-smelling discharge), and intactness of membranes. Reinforce activity restrictions (often limited heavy lifting and intercourse).
Patient Safety and Precautions: Never assume a "tightening" is just Braxton Hicks. Objective monitoring is essential. If active labor is present, the cerclage must NOT be placed. Also, monitor for allergic reactions to any prophylactic antibiotics.
Nursing Procedure & Medication FlowPre-Cerclage Assessment Flow:
1. Client interview (symptoms) → 2. Physical assessment (vital signs, fundal height, palpation) → 3. Electronic fetal monitoring (EFM) for at least 20-30 minutes to rule out regular contractions → 4. Documentation of findings → 5. Report to provider → 6. Proceed with consent/prep if clear.
Medication Note: Prophylactic antibiotics (e.g., Cefazolin 1-2g IV) are often given 30-60 minutes before incision. Verify allergies (especially penicillin/cephalosporin) before administration.
A Word from Your Senior Nurse
"In obstetrics, timing is everything. That 'feeling of tightening' could be nothing, or it could be the start of preterm labor that would make a routine procedure dangerous. Your role as the nurse is to be the detective and the gatekeeper. You gather the objective data that determines the green or red light for surgery. This critical thinking—assessing before acting—is what keeps patients safe and is exactly what the NCLEX tests. Always link your knowledge: the pathophysiology (weak cervix) leads to the treatment (cerclage), which has a major contraindication (labor). Your priority nursing action flows directly from that link."
Cervical Incompetence — A condition characterized by painless dilation and effacement of the cervix during the second trimester, often leading to recurrent pregnancy loss, due to structural or functional weakness of the cervix.
Cervical Cerclage — A surgical procedure where a stitch (suture) is placed around the cervix to provide mechanical support and prevent premature dilation, typically performed prophylactically in the second trimester for cervical insufficiency.
Preterm Labor — Regular uterine contractions occurring before 37 weeks of gestation that cause cervical change (dilation and/or effacement). It is an absolute contraindication for cervical cerclage placement.
Informed Consent — The process of communication between a patient and provider that results in the patient's authorization or agreement to undergo a specific procedure, after understanding the risks, benefits, and alternatives.
Trendelenburg Position — A position where the patient lies supine with the head lower than the pelvis. In obstetric surgery, it may be used to improve surgical exposure by using gravity to retract the uterus.