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

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=542966  
> language: ko  
> subject: Maternal Newborn Health

## 문제

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.

## 보기

1. Encourage increased oral fluid intake to 3-4 liters per day
2. Position the client in Trendelenburg position to improve renal perfusion
3. Monitor for signs and symptoms of preterm labor **✔ 정답**
4. Apply heat to the flank area to reduce pain and promote comfort

**정답: 3**

## 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.

## 심화 해설

Understanding the Priority in Acute Pyelonephritis During Pregnancy

When a pregnant client at 28 weeks gestation presents with acute pyelonephritis, the clinical picture involves more than just a severe urinary tract infection. The physiological changes of pregnancy, including urinary stasis and ureteral dilatation, increase susceptibility to UTIs and their progression to pyelonephritis [3]. The presence of infection, coupled with the systemic inflammatory response evidenced by fever (101.8°F), tachycardia (110 bpm), and an elevated white blood cell count, creates a high-risk scenario for both the mother and the fetus.

The primary danger in this situation is the strong association between pyelonephritis and the onset of preterm labor. The infectious process and the body's subsequent release of inflammatory mediators, such as prostaglandins and cytokines, can directly irritate the uterine muscle and stimulate premature contractions. Research consistently identifies pyelonephritis as a significant risk factor for adverse maternal and neonatal outcomes, including preterm labor, low birth weight, and maternal sepsis [3]. While administering IV antibiotics addresses the underlying cause, the immediate threat to the pregnancy is the potential initiation of labor before the fetus is viable or fully mature.

Analyzing the Answer Choices

The question asks for the priority nursing intervention, which requires a clinical judgment based on the most immediate threat to life and well-being.

*   Option 3 (Correct): Monitoring for signs and symptoms of preterm labor is the priority. The client's condition at 28 weeks gestation with a severe systemic infection places her at imminent risk. The nurse must continuously assess for regular uterine contractions, low back pain, pelvic pressure, changes in vaginal discharge, or rupture of membranes. Early detection allows for prompt intervention, such as tocolysis and antenatal corticosteroid administration, to halt labor and improve fetal lung maturity, directly mitigating the most critical complication.

*   Option 1: Encouraging increased oral fluid intake is an important supportive measure for any UTI to help flush bacteria from the urinary tract. However, in the acute phase of pyelonephritis with fever and tachycardia, the client's hydration status is managed primarily through IV fluids as ordered. This intervention is secondary to the immediate threat of preterm labor.

*   Option 2: Positioning the client in Trendelenburg position is not a standard or appropriate intervention for pyelonephritis. This position could compromise maternal respiratory function and does not specifically improve renal perfusion in this context. It is unrelated to the core pathophysiology and risks at hand.

*   Option 4: Applying heat to the flank area is a comfort measure that can help alleviate local pain and muscle spasm. While providing comfort is a valid nursing role, it is a lower-priority intervention compared to surveillance for a life-altering complication like preterm labor. Using Maslow's hierarchy of needs and the ABC (Airway, Breathing, Circulation) framework, a safety risk that threatens the pregnancy takes precedence over a comfort measure.

The nurse's immediate focus must be on vigilant assessment for the complication most likely to cause a rapid change in the client's status and jeopardize the pregnancy outcome. This aligns with the high-risk nature of pyelonephritis during pregnancy, where the inflammatory response can directly trigger the onset of premature labor [3].References (research sources)

- [3]Prevalence of Urinary Tract Infection and Associated Risk Factors Among Pregnant Women Attending Selected Hospitals, Hargeisa, SomalilandResearch articleSaid MY, Nur KM, Wacays MA, Abdiwali SA, Farah AM. (2026) · DOI: 10.21203/rs.3.rs-9839322/v1

## 임상 시나리오

Clinical Management of Acute Pyelonephritis in Pregnancy

**Priority Assessment:** The primary nursing focus is continuous monitoring for signs of preterm labor, including regular uterine contractions, low back pain, pelvic pressure, or changes in vaginal discharge. Any indication of labor must be reported immediately for tocolytic intervention if appropriate.

**Fetal Surveillance:** Initiate continuous electronic fetal monitoring to assess fetal heart rate patterns and uterine activity. A nonreassuring fetal status may indicate maternal sepsis or fetal intolerance to the infectious process, necessitating urgent escalation of care.

**Antibiotic Administration:** Administer intravenous antibiotics as prescribed without delay, typically a cephalosporin or ampicillin-gentamicin combination. Ensure blood and urine cultures are obtained prior to the first dose to guide targeted therapy.

**Maternal Monitoring:** Closely track vital signs, particularly temperature and heart rate, to evaluate the response to treatment. Monitor for signs of sepsis such as hypotension, altered mental status, or tachypnea. Strict intake and output monitoring is essential to ensure adequate renal function and hydration status.

**Comfort and Positioning:** Position the client in a left lateral recumbent position to optimize uterine perfusion and renal blood flow. Administer antipyretics as ordered for fever management, as hyperthermia is detrimental to the fetus. Apply heat packs to the flank only after the immediate risk of preterm labor has been ruled out or stabilized.

## 핵심 개념

- **Acute Pyelonephritis** — A bacterial infection causing inflammation of the renal pelvis and kidney tissue, often presenting with fever, chills, flank pain, and dysuria.
- **Preterm Labor** — Regular uterine contractions causing cervical change before 37 weeks of gestation, a major complication of pyelonephritis due to the release of inflammatory mediators.
- **Inflammatory Mediators** — Substances like prostaglandins and cytokines released during infection that can irritate the uterine muscle and trigger premature contractions.
- **Ureteral Dilatation** — A physiological change in pregnancy where the ureters widen due to hormonal effects and mechanical compression, increasing the risk of urinary stasis and infection.
- **Maternal Sepsis** — A life-threatening organ dysfunction caused by a dysregulated host response to infection, a potential severe complication of untreated pyelonephritis.

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