A nurse is caring for a female client who is gravida 1 para 0 at 32 weeks of gestation in the antepartum unit. Complete the following sentence by using the list of options. The nurse should identify that ____________ and ___________ are findings that require follow-up.
Explanation & Rationale
The nurse should identify that weeks of gestation and contraction pattern are findings that require follow-up. Rationale for correct answers: Weeks of gestation at 32 weeks indicate a preterm pregnancy (<37 weeks), making any contractions concerning for possible preterm labor. The contraction pattern of increasing frequency (from every 5 minutes to every 3 minutes), longer duration (30 to 60 seconds), and moderate intensity signifies active uterine activity that can precipitate cervical changes and preterm birth risk. These two parameters warrant close monitoring and intervention to prevent premature delivery. Rationale for incorrect answers (Response 1 options): Blood pressure is within normal limits (128/83 and 117/80 mm Hg), so hypertensive disorders like preeclampsia are not indicated here. Pain score remains low (2/10), which is mild and not a primary indicator for urgent intervention. Parity (G1P0) does not influence immediate risk assessment for this clinical presentation. Rationale for incorrect answers (Response 2 options): Fetal heart rate remains normal at 140/min with no decelerations, indicating fetal well-being at this time. Nitrazine test is negative, showing intact membranes, which reduces the risk of premature rupture of membranes. Temperature is normal at 37°C, ruling out infection as a cause of contractions. Therefore, these findings do not require urgent follow-up in this scenario.