HELP with preterm labor care plan

Published

My teacher has assigned me a case study for our L&D clinical. I am new at this can anyone help me with top priority nursing diagnosis??

32-year-old G40212 at 32+2 weeks presenting to L&D with lower back pain, intermittent contractions and increased mucus-like lady partsl discharge. She has delivered all babies lady partslly. She had a cerclage placed at 21 weeks gestation and denies any complications from the cerclage placement. has a history of chlamydia and gonorrhea that was treated 2 weeks ago. She is recently divorced but has family support. She is concerned and anxious but aware of risks of early delivery due to her prior preterm births. She has a pain score of 3/10 and requests pain medication. According to a sterile speculum exam her cervix is approximately 1cm dilated. She denies alcohol and drug use but admits to smoking a half a pack of cigarettes a day. Her current VS are as follows: PB: 110/65, HR 75, RR:18, and T 98.4. She had a an IV stared to her right hand with LR infusing at 125cc/hr.The fetal heart rate is 130's with moderate variability and accelerations.

I have come up with

Risk for infection related to cerclage and possible complication PROM

Acute pain related to intermittent contractions

Anxiety related to threat of maternal/fetal well being secondary to risk of preterm labor

Knowledge deficit related to effects of smoking during pregnancy

Up Vote Up Vote ×
+ Join the Discussion