Maternal Child Health Nursing

Full Answer Section

• Current symptoms: The nurse should assess the client's current symptoms, including the frequency and intensity of uterine contractions, the amount of vaginal bleeding, and any other symptoms, such as nausea, vomiting, or diarrhea.
• Fetal well-being: The nurse should assess the fetal well-being by monitoring the fetal heart rate and uterine activity.

• Monitor the client's vital signs: The nurse should monitor the client's vital signs, including her temperature, pulse, respirations, and blood pressure.
• Monitor the fetal heart rate: The nurse should monitor the fetal heart rate using a fetal monitor.
• Administer medications as ordered: If the client is diagnosed with preterm labor, the nurse will administer medications as ordered by the healthcare provider. These medications may help to stop preterm labor or delay delivery.
• Provide emotional support: The nurse should provide emotional support to the client and her family. This may include listening to their concerns, providing information about preterm labor, and helping them to make decisions about their care.

• Cervical length: The nurse may measure the client's cervical length to assess her risk for preterm labor. A cervical length of less than 2.5 centimeters is considered to be a risk factor for preterm labor.
• Fetal fibronectin: The nurse may test the client for fetal fibronectin, a protein that is released from the cervix and vagina during preterm labor. A positive fetal fibronectin test is also considered to be a risk factor for preterm labor.
• Biophysical profile: The nurse may perform a biophysical profile, which is a test that evaluates the fetus's well-being. The biophysical profile includes ultrasound measurements of the fetus's breathing movements, body movements, tone, and amniotic fluid volume.

Sample Solution

• History of preterm labor: The nurse should obtain a detailed history of the client's previous preterm labor, including the gestational age at which labor occurred, the length of labor, and any complications.
• Risk factors for preterm labor: The nurse should assess the client for risk factors for preterm labor, such as a history of preterm birth, multiple gestation, or cervical insufficiency.