A nurse is caring for a female client who is at 30 weeks of gestation in the labor and delivery unit. Exhibits For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.
Explanation & Rationale
Collect urine and vaginal cultures — Anticipated: Obtaining urine and vaginal cultures is appropriate given rupture of membranes (nitrazine positive, clear fluid on pad), maternal fever (38.3°C), leukocytosis (WBC 22,000/mm³) and vaginal bleeding. Cultures identify pathogens (urinary tract infection, Group B Streptococcus, chorioamnionitis organisms) to guide targeted intrapartum antibiotics and neonatal prophylaxis. Early microbiologic data reduce empiric therapy duration, allow appropriate antibiotic selection, and inform neonatal sepsis risk stratification. Assess the client's blood glucose levels every 30 min — Nonessential: Frequent half-hour glucose monitoring is not routinely required absent diabetes or use of therapies that acutely alter glycemia (e.g., intravenous dextrose, insulin infusion). Betamethasone can cause hyperglycemia, but standard practice is periodic glucose checks rather than every 30 minutes. Given no documented diabetes and no insulin therapy, continuous every-30-minute checks would be excessive; targeted monitoring (baseline and several checks after corticosteroid administration) is appropriate. Terbutaline 0.25 mg subcutaneous now — Contraindicated: Tocolysis with β-agonists is contraindicated when intrauterine infection or chorioamnionitis is suspected because delaying delivery increases maternal and fetal morbidity. Maternal fever, leukocytosis, and PROM with clear fluid strongly suggest infection risk; terbutaline would mask signs, increase maternal tachycardia, and may worsen maternal instability. Additionally, maternal fever and possible sepsis make tocolysis unsafe because it prolongs fetal exposure to infected intrauterine environment. Place an 18-gauge intravenous catheter for IV fluids — Anticipated: An 18-gauge IV is indicated for rapid access to administer antibiotics, magnesium sulfate loading dose, and potential blood products or emergent fluids. The presence of preterm labor with PROM, maternal fever, and planned IV medications (magnesium, antibiotics) requires reliable large-bore access to ensure rapid delivery of medications, fluid resuscitation if sepsis or hemorrhage occurs, and to permit blood sampling. Prepare magnesium sulfate IV — Anticipated: At 30 weeks’ gestation, magnesium sulfate for fetal neuroprotection is indicated if preterm birth is imminent (generally <32 weeks). Preparation is appropriate given active contractions, cervical change (2 cm, 80% effaced), and probable ROM. Magnesium reduces risk of cerebral palsy when given prior to very preterm delivery. Ensure maternal contraindications (myasthenia gravis, severe renal impairment) are absent and monitor respiratory rate, deep tendon reflexes, and urine output. Provide intermittent fetal monitoring — Nonessential: Intermittent auscultation is inadequate in this clinical context. Maternal fever, PROM, active contractions, and prior cesarean increase risk of fetal compromise and require continuous electronic fetal monitoring (EFM) to detect tachycardia, decelerations, or changes that would prompt delivery. Thus "intermittent monitoring" is nonessential and suboptimal; continuous monitoring is anticipated instead. Betamethasone 12 mg IM now and repeat in 24 hr — Anticipated: Antenatal corticosteroids given between 24 and 34 weeks accelerate fetal lung maturation and reduce neonatal respiratory distress syndrome, intraventricular hemorrhage, and neonatal mortality. At 30 weeks with active preterm labor and PROM, betamethasone is indicated even with maternal infection pending obstetric judgment, because fetal benefit is substantial when preterm delivery is likely. Monitor maternal glucose after administration due to steroid-induced hyperglycemia.