A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following actions should the nurse take?

A. Urinalysis: The urinalysis shows leukocyte esterase positivity, which suggests a possible urinary tract infection rather than an indication of labor. While infections can contribute to discomfort and complications, urinalysis findings do not confirm the onset of labor and therefore are not considered indicators of labor progress.

B. Contraction intensity: The client reports contractions that are becoming stronger over the last few hours, with pain rising to 8 out of 10 during contractions. Increasing contraction intensity is a typical sign that labor is progressing, as contractions become more forceful and effective in promoting cervical change.

C. Cervical dilation: The last cervical exam was performed five days ago and showed no dilation, and the current scenario provides no evidence of updated cervical assessment. Without current cervical findings, dilation cannot be used as an indicator of labor at this time, even though it is a defining feature when assessed directly.

D. Vaginal discharge: The client has been wearing a perineal pad for discharge for three days, but this chronic discharge does not necessarily represent labor onset. Vaginal discharge can increase during pregnancy for many benign reasons and requires nitrazine testing or other characteristics to confirm rupture of membranes.

E. Nitrazine results: The nitrazine test is positive, which suggests that the fluid may be amniotic rather than standard vaginal secretions. Rupture of membranes, whether spontaneous or premature, is an important sign associated with labor or imminent labor progression and requires follow-up assessment.

F. Maternal temperature: The temperature of 38.7°C (101.7°F) indicates a fever and raises concern for infection, such as chorioamnionitis or a urinary infection. A fever does not indicate labor directly; instead, it signals a need for medical evaluation to determine the cause and potential fetal implications.

G. Contraction frequency: Contractions occurring every five minutes for at least one hour suggest a rhythmic pattern typical of early labor. When contractions become regular and progressively closer together, this pattern is consistent with true labor rather than Braxton Hicks contractions.

H. Fetal heart rate: The fetal heart rate of 140 beats per minute is within normal limits for a term fetus and does not indicate labor progression. FHR trends help evaluate fetal well-being but do not provide specific information confirming the presence or advancement of labor.

A. A client who has gastroenteritis and is lethargic and confused: Lethargy and confusion indicate significant fluid and electrolyte imbalances, possibly severe dehydration, which can rapidly become life-threatening. Gastroenteritis can cause profound fluid loss, and these neurological changes suggest urgent intervention is needed to prevent shock or other complications.

B. A client who has cystic fibrosis, has a thick, productive cough and reports thirst: Thick secretions and thirst are expected concerns in cystic fibrosis due to chronic pulmonary involvement and potential dehydration. While important to address, these symptoms are less immediately life-threatening compared to altered mental status.

C. A client who has sickle cell anemia and reports pain 15 min after receiving analgesic: Pain is a common and expected symptom in sickle cell crises. The client may require additional pain management, but this finding does not indicate immediate life-threatening issues. The nurse can prioritize this after addressing the client with altered mental status.

D. A client who has diabetes mellitus and has a morning fasting capillary glucose of 185 mg/dL: This elevated glucose requires monitoring and possible adjustment of treatment but is not acutely life-threatening. Hyperglycemia of this level can be managed according to the provider’s plan, so it is not the highest priority for immediate reporting.