The charge nurse is reviewing charting completed on clients in the maternal–child triage unit. Which entry requires immediate intervention?
1. Multipara at 32 weeks: "Oligohydramnios per ultrasound secondary to fetal renal agenesis."
2. Primipara at 41 weeks: "Client reports leaking clear fluid from her vagina for 7 hours."
3. Primipara at 24 weeks diagnosed with polyhydramnios: "Client reporting shortness of breath."
4. Multipara at 34 weeks diagnosed with oligohydramnios: "Cervix 6 cm, ?2 station, up to walk in hallway."
4
Explanation:
1. 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.
2. 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 it is a lower priority than the client with the possibility of a prolapsed cord.
3. 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.
4. Active labor in a preterm multipara 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 bed rest until the membranes rupture and the presenting part has descended well into the pelvis. This client is at the highest risk for physical complication (cord prolapse) and therefore is the highest priority.
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