# A pregnant client is diagnosed with acute pyelonephritis. Which nursing intervention should be the priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=542965 > language: ko > subject: Maternal Newborn Health ## 문제 A pregnant client is diagnosed with acute pyelonephritis. Which nursing intervention should be the priority? A 26-year-old pregnant woman at 28 weeks gestation presents to the emergency department with complaints of severe flank pain, fever of 101.8°F (38.8°C), chills, nausea, and vomiting. Laboratory results show elevated white blood cell count and positive urine culture for E. coli. The physician diagnoses acute pyelonephritis and orders IV antibiotic therapy. ## 보기 1. Encourage increased oral fluid intake to 3-4 liters per day 2. Position the client in left lateral recumbent position 3. Monitor maternal vital signs and fetal heart rate continuously **✔ 정답** 4. Administer prescribed analgesics for pain management **정답: 3** ## 해설 Continuous monitoring of maternal vital signs and fetal heart rate is critical due to risks of sepsis and preterm labor. Other interventions like fluid intake and pain management are important but secondary to early detection of complications. ## 심화 해설 Understanding the Priority: Maternal-Fetal Surveillance in Pyelonephritis When a pregnant client presents with acute pyelonephritis, the physiological stakes are uniquely high due to the profound changes of gestation. The provided case report underscores that urinary tract infections in pregnancy are a significant clinical concern, with an estimated 15 to 20% of acute pyelonephritis cases potentially progressing to bacteremia [1]. This risk is amplified in the presence of complicating factors like urinary stones, and the cascade can rapidly advance to sepsis, septic shock, and multiple organ dysfunction, adversely affecting the kidneys, liver, lungs, heart, and central nervous system [1]. The immediate priority is not just treating the infection, but continuously assessing for the earliest signs of this dangerous progression and its direct impact on the fetus. Why Continuous Monitoring is the Priority Intervention The correct answer is to monitor maternal vital signs and fetal heart rate continuously. This intervention directly addresses the most immediate threat identified in the source material: the rapid deterioration from a localized infection to a systemic, life-threatening condition. - Early Detection of Sepsis and Septic Shock: The progression from pyelonephritis to bacteremia and septic shock involves a systemic inflammatory response that manifests first in altered vital signs. Continuous monitoring allows the nurse to detect subtle but critical changes—such as increasing heart rate, dropping blood pressure, rising or falling temperature, and changes in respiratory rate—that signal the onset of sepsis [1]. Given that the condition can lead to multiple organ dysfunction, identifying these trends in real-time is essential for triggering immediate medical interventions to prevent refractory shock. - Direct Fetal Consequence of Maternal Instability: The fetus is entirely dependent on maternal hemodynamic stability. In the context of septic shock, maternal hypotension and hypoperfusion directly compromise uterine blood flow and oxygen delivery to the fetus. The fetal heart rate is a real-time indicator of fetal well-being and uteroplacental sufficiency. Late decelerations, tachycardia, or a loss of variability would be the earliest signs of fetal distress secondary to maternal sepsis. Continuous electronic fetal monitoring is the only way to capture this data and intervene before irreversible harm occurs. Why Other Options Are Not the Priority While all the listed interventions are components of comprehensive care, they do not address the immediate, life-threatening risk of systemic decompensation. - Encouraging Oral Fluid Intake: Although hydration is important for managing pyelonephritis, a client with severe nausea, vomiting, and a risk of sepsis may not tolerate oral intake and is at risk for aspiration. More critically, this is a supportive measure, not a surveillance strategy. It does not provide the data needed to detect the onset of septic shock, which is the priority concern based on the case report’s description of disease progression [1]. - Positioning in Left Lateral Recumbent: This position is a standard intervention to relieve aortocaval compression and improve venous return and placental perfusion. However, it is a single, static action. The dynamic risk of a client deteriorating from pyelonephritis to septic shock requires continuous assessment, not just a one-time positioning. The position can be implemented concurrently, but the act of monitoring is what will reveal if the positioning is effective or if the client’s condition is worsening. - Administering Prescribed Analgesics: Pain management is an important comfort and safety measure, as severe pain can increase physiological stress. However, administering analgesics before a complete and ongoing assessment of hemodynamic and fetal status could mask important clinical signs. The priority is to establish a monitoring baseline and trend to ensure the client is stable before and after providing medications that may alter vital signs. The core clinical reasoning here is that the source material frames acute pyelonephritis in pregnancy as a precursor to a potential maternal near-miss event involving refractory septic shock [1]. The nursing priority, therefore, must be the intervention that provides continuous, real-time data on both the maternal systemic response and the fetal condition, enabling early recognition of this life-threatening trajectory.References (research sources) - [1]Case Report: Maternal near-miss-recovery from refractory septic shock with multiple organ dysfunction secondary to acute pyelonephritis in pregnancy.Case reportChen H, Huang Z, Chen G, Tang Y, Yang D. (2025) · DOI: 10.3389/fmed.2025.1671969 ## 임상 시나리오 Clinical Practice Guide: Prioritizing Care in Pregnant Patient with Acute Pyelonephritis **Clinical Scenario:** A 28-week gravid patient presents with fever, flank pain, and a positive urine culture for E. coli. The immediate risk is rapid progression from a localized infection to systemic sepsis, which can trigger preterm labor and fetal compromise. Immediate Priority: Continuous Maternal-Fetal Surveillance The highest priority nursing action is to establish continuous monitoring of maternal vital signs and fetal heart rate. This is not merely a task but a critical assessment strategy to detect the earliest signs of decompensation. - **Maternal Monitoring:** Track temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation every 15-30 minutes initially. Tachycardia, tachypnea, and widening pulse pressure are early indicators of systemic inflammatory response syndrome (SIRS) progressing to sepsis. - **Fetal Monitoring:** Initiate continuous electronic fetal monitoring. Maternal fever and dehydration can directly cause fetal tachycardia (>160 bpm for >10 minutes). Late decelerations or minimal variability may indicate fetal hypoxemia secondary to maternal hypotension or placental hypoperfusion. Sequential Interventions After Stabilization Once continuous monitoring is in place and the patient is stable, other critical interventions can be implemented concurrently or sequentially: - **Administer IV Antibiotics:** Initiate the prescribed broad-spectrum IV antibiotic (e.g., ceftriaxone) immediately after blood and urine cultures are obtained. Do not delay antibiotics to complete monitoring setup. - **Fluid Resuscitation:** Administer IV isotonic crystalloids (e.g., Lactated Ringer's or Normal Saline) as ordered to correct dehydration from fever and vomiting, and to maintain adequate urine output (>30 mL/hr) and placental perfusion. - **Positioning:** Once continuous monitoring confirms fetal well-being, position the patient in the left lateral recumbent position to maximize uteroplacental blood flow and reduce compression of the vena cava. - **Symptom Management:** Administer prescribed antipyretics (e.g., acetaminophen) for fever >38.0°C and analgesics for pain only after the initial assessment and stabilization are complete. Key Clinical Pearls - **Never ignore a single spike in temperature or heart rate.** In pregnancy, physiological reserves are altered, and decompensation can be rapid. - **Fetal tachycardia is a maternal emergency.** It is often the first sign of maternal sepsis or chorioamnionitis. - **Oral intake is contraindicated initially.** A patient with nausea, vomiting, and risk of sepsis should be NPO (nothing by mouth) until stability is confirmed, making option 1 (increased oral fluids) inappropriate as a priority. ## 핵심 개념 - **Acute Pyelonephritis in Pregnancy** — A bacterial infection of the upper urinary tract during pregnancy, carrying a high risk of progression to bacteremia, sepsis, and preterm labor, requiring aggressive IV antibiotic therapy and close surveillance. - **Maternal-Fetal Surveillance** — Continuous or frequent monitoring of maternal vital signs (temperature, heart rate, blood pressure, respiratory rate, oxygen saturation) and fetal heart rate to detect early signs of maternal deterioration or fetal distress. - **Prioritization in Nursing** — The process of determining which patient needs or problems require immediate intervention based on the potential for rapid clinical deterioration, following frameworks like Maslow's hierarchy or the ABCs (Airway, Breathing, Circulation). - **Bacteremia and Sepsis** — Bacteremia is the presence of bacteria in the blood. Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection, often first signaled by changes in vital signs (fever, tachycardia, tachypnea, hypotension). ## 같은 주제 문제 - [A pregnant client at 24 weeks gestation presents to the clinic with complaints of urinary …](https://mymerci.kr/pages/nclex_q.php?qn_id=542963) - [A pregnant client at 28 weeks gestation presents to the clinic with complaints of urinary …](https://mymerci.kr/pages/nclex_q.php?qn_id=542964) - [A pregnant client at 28 weeks gestation is diagnosed with acute pyelonephritis. Which nurs…](https://mymerci.kr/pages/nclex_q.php?qn_id=542966) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._