CASE SIMULATION 117

Name: Marquez, Caren Joy B. Class/Group: 6

INSTRUCTION. All questions apply to this case study. Your responses should be brief and to the
point. When asked to provide several answers, list them in order of priority of significance. Do
not assume information that is not provided. Please print or write clearly. If your response is
not legible, it will be marked as (?), and you will need to rewrite it.

Scenario
P.T. is a married 30-year-old gravida 4, para 1203 at 28 weeks’ gestation. She arrives in the
labor and delivery unit at a level 2 hospital complaining of low back pain and frequency of
urination. She states that she feels occasional uterine cramping and believes that her
membranes have not ruptured.

1. You are the charge nurse and admit PT. based on the information you have been given,
identify the two most likely diagnoses for P.PT.
 Pre-term labor (The patient is in her third trimester (28 weeks), causing frequent urination
(due to baby pushing on the bladder) and increasing weight gain can cause back pain.)
 UTI (due to pressure on the bladder and more exposure to bacteria.)

2. You need additional information from PT to determine what you will do next. What
important questions do you need to ask to differentiate what is going on with P.T.?
 When did you first notice your symptoms?
 Have you been treated for a bladder or kidney infection in the past?
 How severe is your discomfort?
 How often do you urinate?
 Are your symptoms relieved by urinating?
 Have you had a fever?
 Have you noticed vaginal discharge or blood in your urine?
 Are you being treated for any other medical conditions?
 What does the pain feel like? Sharp or dull? Continuous or intermittent? What is the level of
your low back pain on a scale of 1 out of 10?
 When did this pain start?
 Where does it hurt the most? Does it radiate or go to any other part of your body?
 How long does the pain last? Does it come and go or is it constant?
 What makes your back pain worse or better? Are there any treatments you have tried that
relive the pain?
3. What actions would you take to help identify her underlying problem before calling the
health care provider?
For preterm labor:
 Fundal height (measure of the size of the uterus used to assess fetal growth and
development during pregnancy)
 Leopold's maneuvers (for fetal position)
 Cervical examination to determine dilation and effacement
 Monitor fetal heart tones and contraction pattern with external monitors
For UTI:
 Obtain a clean-catch urine specimen and send for urinalysis and culture & sensitivity. Obtain
the specimen before connecting patient to the electronic uterine monitor.
 Take vital signs. (to detect possibility of fever, tachycardia and hypotension)

4. Early recognition of preterm labor is essential to successfully implement interventions.

The diagnosis of preterm labor is based on what three major diagnostic criteria?
 Gestational age between 20-37 weeks
 Presence of contractions (uterine activity)
 Progressive cervical change (e.g., cervical effacement of 80% or cervical dilation of 2 cm or
greater)

5. What is the significance of misdiagnosing preterm labor?

The misdiagnosis of preterm labor can lead to the inappropriate use of pharmacologic agents
that can be dangerous to the health of the woman, fetus, or both.

6. What other problems might be going on with PT that you should consider?
It may be that patient is having actual preterm, back labor. Her fetus may be in a posterior
presentation, thus explaining the lower back pain and the cramping. It may also be back pain
and frequency of urination related to the typical bodily changed associated with pregnancy.
CASE STUDY PROGRESS
P.T.’s history reveals that she had one pre term delivery 4 years ago at 32 weeks gestation. The
infant girl was in the neonatal intensive care unit (NICU) for 3 weeks and discharge without
sequelae. The second preterm infant, was delivered two years ago at 35 weeks age of gestation
and spent 4 days in the hospital before discharge. She has no other risk factors for preterm
labor. Vital signs are normal. Her vaginal examination was essentially within normal limits:
cervix long, closed and thick; membranes intact. Abdominal examination revealed that the
abdomen was nontender, with fundal height of 29cm, fetus in vertex presentation.
7. While waiting for laboratory results, what therapeutic measures do you consider?
 Encourage rest.
 Hydration calms the uterus if there are mild contractions. Give water.
 Assess for the presence of contractions.

8. When caring for a woman with history of preterm labor, it is important to question the
woman about whether she has symptoms when she engaged in certain activities that
might require lifestyle modifications. What activities should you assess for?
 Sexual activity
 Riding long distances without being able to stretch legs or stand
 Carrying heavy loads or carrying a child often
 Standing more than 50% of her day
 Hard physical work
 Being unable to stop and rest when tired
 Climbing stairs
 Limited or no assistance with household work and caring for other children

CASE STUDY PROGRESS

While waiting for laboratory results, you consider that P.T. is experiencing preterm labor, she
would receive antenatal glucocorticoids.
9. What is the rationale for the administration of antenatal glucocorticoids for preterm
labor?
Antenatal glucocorticoids such as dexamethasone and betamethasone are given to accelerate
fetal lung maturity and thereby prevent or reduce the severity of respiratory distress syndrome
in preterm infants between 24 and 34 weeks of gestation. Antenatal corticosteroids are
effective in reducing respiratory distress syndrome (RDS) and other complications of premature
deliveries.

10. How long do these drugs take to become effective?

24 hours after administration (IM)

11. Which of these situations are considered contraindications to antenatal glucocorticoids

when a woman is in preterm labor (Select all that apply.)
a. Cord collapse (when the cord drops through the open cervix into the vagina before the baby
moves into the birth canal)
b. Chorioanmnionitis (intrauterine bacterial infection)
c. Presence of twin fetus
d. Cervical dilatation of 2.5cm
e. Abruption placenta (premature separation of the placenta from the uterus)
CASE STUDY OUTCOME
Two hours later, the laboratory results indicate a urinary tract infection. The contraction
monitor indicates infrequent, mild contraction. Her physician discharges her to home on an
antibiotic for UTI.
12. What follow-up measures should be considered in providing P.T. discharge instruction?
 What is her nutritional status? Is she taking time to eat a balanced diet?
 Is she drinking enough fluids? Stress importance of consuming at least 2L (8 glasses of fluid
daily).
 Caffeine is a diuretic and should be avoided.
 Avoid bubble bath or bath oils and scented toilet paper because it can irritate the urethra.
 Urinate before and after sex.
 Assess understanding of when and how to take antibiotic if she has problems.
 Review signs and symptoms of preterm labor and risk factors.
 She should be seen by the health care provider again within one week.