The nurse has reviewed the Vital Signs and Nurses' Notes from 5 weeks ago.

Click to highlight the findings the nurse should report to the provider. To deselect a finding, click on the finding again.

Body System	Findings
Gastrointestinal	Client states, "I'm nauseated all the time. I vomit a few times a day, too." Client states, "I've been a little constipated, but it's not too bad." Abdomen without tenderness on palpation. Bowel sounds hypoactive. Oral mucous membranes sticky.
Genitourinary	Also reports they are urinating less and that urine is dark yellow and odorous. Clean-catch urine specimen obtained. Urine noted to be dark yellow and concentrated
Cardiovascular	Heart rate regular. No edema. Heart rate 92/min Blood pressure 102/66 mm Hg

 

A. Food stamps: Supplemental Nutrition Assistance Program (SNAP), commonly called food stamps, provides financial assistance for purchasing nutritious food. For a client below the poverty level, this resource helps ensure adequate nutrition, which is essential for recovery during home IV therapy.

B. Medicaid: Medicaid offers health coverage for low-income individuals, including coverage for home health services and necessary medical equipment. Enrolling the client in Medicaid can facilitate access to home IV therapy and reduce out-of-pocket expenses.

C. Respite care: Respite care provides temporary relief to caregivers but is not directly relevant to a young adult client managing home IV therapy independently. While useful in certain situations, it is not a primary resource for financial or medical support in this case.

D. Medicare Part A: Medicare primarily covers hospital and skilled nursing facility care for adults over 65 or with certain disabilities. A young adult below the poverty level is unlikely to qualify, making this an inappropriate recommendation for home IV therapy coverage.

E. Adult day care: Adult day care services are designed for older adults requiring supervision or social interaction. This service is not applicable for a young adult client requiring home IV therapy and does not address financial or medical support needs.

Rationale:

• Obtain daily weights: Daily weights are used to monitor fluid balance in conditions like preeclampsia or heart failure. In this acute preterm labor scenario, the priority is monitoring fetal well-being and uterine activity, not long-term fluid shifts.

• Administer terbutaline: Terbutaline is a tocolytic medication used to suppress preterm labor by relaxing uterine smooth muscle. Given the client’s regular, strong contractions at 33 weeks with cervical changes, terbutaline may be prescribed to delay labor and allow fetal maturation.

• Administer oxytocin: Oxytocin stimulates uterine contractions and is used to induce or augment labor. In a client experiencing preterm labor at 33 weeks, oxytocin is contraindicated because it could worsen labor progression and increase risk of preterm birth.

• Administer betamethasone: Betamethasone is a corticosteroid administered to accelerate fetal lung maturity when preterm birth is imminent. Since the client is 33 weeks gestation and showing signs of preterm labor, administration is anticipated to reduce neonatal respiratory complications.

• Maintain modified bed rest with bathroom privileges: Modified bed rest can help reduce uterine stimulation, conserve energy, and support uteroplacental perfusion in clients experiencing preterm labor. Limiting physical activity is a standard intervention for preterm labor management.