A nurse is assisting with the care of a client.

Exhibits

For each data collection finding, dick to specify if the finding is consistent with ulcerative colitis, diverticulitis, or Crohn's disease. Each finding may support more than 1 disease process.

Rationale for Correct Choices:

Chorioamnionitis is a bacterial infection of the amniotic fluid and fetal membranes, which can develop when the protective barrier is compromised due to prolonged rupture of membranes. This client reported clear fluid discharge the previous evening, indicating that the membranes have been ruptured for an extended period. The risk of infection increases significantly as time progresses. Additionally, the client exhibits signs of maternal restlessness and increased fetal heart rate, which could indicate an early response to infection or fetal distress.

Hemorrhage is a significant risk during labor, especially as the cervix approaches full dilation and the client exhibits increasing amounts of blood-tinged vaginal discharge. The client’s history of previous pregnancy loss and current cervical changes suggest that monitoring for postpartum hemorrhage will be essential, particularly after delivery.

Rationale for Incorrect Choices:

Disseminated intravascular coagulopathy is a severe complication associated with conditions such as placental abruption, preeclampsia, or amniotic fluid embolism. However, this client does not exhibit hallmark signs such as widespread bruising, uncontrolled bleeding, or abnormal clotting, making this a less likely immediate risk.

Seizures are characteristic of eclampsia, which is typically preceded by severe preeclampsia. While the client is restless and experiencing significant pain, there are no findings of hypertension, hyperreflexia, or neurological disturbances such as visual changes or altered mental status, making seizures an unlikely concern at this time.

Preeclampsia is a hypertensive disorder of pregnancy characterized by elevated blood pressure, proteinuria, and systemic symptoms. This client has stable blood pressure readings within the normal range, no evidence of proteinuria, and no indications of significant organ dysfunction, making preeclampsia an unlikely concern.

Dehydration is a potential concern due to the client’s nausea, vomiting, and lack of recent oral intake. However, there are no immediate signs of hemodynamic instability, such as hypotension or tachycardia, suggesting that dehydration is not the most pressing concern at this moment.

A. Medical health insurance claims. While insurance coverage is important for referral approval, the physical therapist primarily requires clinical information related to the client's mobility and functional status. Insurance details are handled by administrative staff rather than included in the clinical referral.
B. Physical assessment findings. The physical therapist needs relevant assessment findings, such as muscle strength, range of motion, balance, gait, and mobility limitations. These details help guide therapy goals and interventions to improve the client’s functional abilities.
C. Family medical history. While family history is useful for identifying genetic predispositions to conditions, it is not essential for a physical therapy referral. The focus should be on the client’s current physical status rather than hereditary factors.
D. Medications taken prior to admission. Although a client’s medication history is important for overall care, it is not the primary concern for a physical therapy referral unless specific medications affect mobility, such as muscle relaxants or sedatives. The therapist will rely more on current physical assessment findings to determine appropriate interventions.