A pregnant woman in her second trimester arrives at the labor unit triage station with complaints of lower abdominal cramping and urinary frequency. Appropriate nursing actions include which of the following? (Select all that apply.)
A.
Assess the fetal heart rate.
B.
Assess the patient's pulse rate.
C.
Insert an indwelling Foley catheter.
D.
Obtain a urine sample for culture and sensitivity.
E.
Palpate the patient's abdomen for contractions.
ANS: A, B, D, E
Women who experience preterm labor may complain of backache, pelvic aching, menstrual-type cramps, increased vaginal discharge, pelvic pressure, urinary frequency, and intestinal cramping with or without diarrhea. A urinalysis and urine culture and sensitivity should be obtained on all patients with symptoms of preterm labor, and the nurse must remember that symptoms of urinary tract infection often mimic normal pregnancy complaints (e.g., urgency, frequency). The patient's abdomen should be palpated to assess for contractions, and the fetal heart rate should be monitored. It is not necessary to insert a Foley catheter at this time.
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