The charge nurse is reviewing charting on clients in the maternal–child triage unit. Which entry requires immediate intervention?
1. Primip at 24 weeks diagnosed with polyhydramnios: "Client reporting shortness of breath."
2. Multip at 32 weeks: "Oligohydramnios per ultrasound secondary to fetal renal agenesis."
3. Primip at 41 weeks: "Client reports leaking clear fluid from her vagina for seven hours."
4. Multip at 34 weeks diagnosed with oligohydramnios: "Cervix 6 cm, ?2 station, up to walk in hallway."
4
Rationale:
1. Although this client is uncomfortable, shortness of breath often accompanies polyhydramnios. It can require removal of some amniotic fluid through amniocentesis to facilitate comfort, but this is not a life-threatening emergency.
2. Renal agenesis will lead to oligohydramnios because of the lack of fetal urine production. This client will be grieving, but is not experiencing physical complications.
3. Leakage of clear fluid is normal; leaking for several hours can lead to oligohydramnios, which in turn can lead to variable decelerations. This client might be experiencing a complication, but is a lower priority than the client with the possibility of a prolapsed cord.
4. Active labor in a preterm multip with the presenting part high in the pelvis is at high risk for prolapse of the cord when the membranes rupture. This client should be on bedrest until the membranes rupture and the presenting part has descended well into the pelvis. This client is at highest risk for physical complication (cord prolapse), and therefore is the highest priority.
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