Question

Gloria Harjo is a pregnant primigravida at 39 weeks of gestation.  She arrives at the birthing center triage unit with complaints of lower abdominal pains for the past 4 hours. Gloria is accompanied by her husband, Victor. Gloria clenches Victor’s hand and holds her breath each time she has a contraction. Gloria’s breathing pattern is rapid and shallow and she appears to be nervous, tense, and in pain. She states that she is fearful because she doesn’t know what to expect.

Gloria’s assessment findings are as follows:

Vital signs:

Temperature = 99°F

Pulse = 90 beats/minute

Respirations = 32 breaths/minute

Blood pressure = 110/58 mm Hg

Uterine contractions occurring every 4–5 minutes, 45–55 seconds in duration, mild to moderate in intensity

Fetal heart rate of 126–130 beats per minute with accelerations to 160 beats per minute

Cervical examination: Cervix 4 cm dilated, 80% effaced, vertex at –1 station, membranes intact

Critical Thinking Questions

1. What are the priority nursing diagnoses at this time?

2.  What are the expected outcomes associated with these diagnoses?

3. Describe the teaching/learning needs related to the scenario that correspond to the priority nursing diagnoses.

4. List interventions with rationales that correspond to the priority nursing diagnoses.

Answer 1

1.The priority nursing diagnosis for the patient at this point is to manage the elevated body temperature in order to prevent complications in the fetus

• Impaired thermoregulation related to intrauterine infection as evidenced by elevated body temperature

2.The exoected outcome is

• The mother will be having a normal body temperature or normothermic

3.Intervention and rationale

• Monitor vital signs continuously ,to note and adress any changes immediately
• Watch for seizure and take preventive measures
• Administer intravenous fluid to reduce body temperature
• Administer antibiotics as per order to treat any infection
• Administer antipyretics to reduce temperature as per order

Teaching/learning needs

• Provide psychological support and positive reinforcement
• Support the mother and family that this is treatable