The nurse is interviewing a client who is 36 weeks pregnant. Which of the following statements, if made by the client, would require immediate intervention by the nurse?

Question

1. "I have to get up during the night to void.".
2. "I have not felt the baby move today.".
3. "I am leaking a yellowish fluid from my breasts.".
4. "I have been taking Tylenol (acetaminophen) for my backaches.".

Answer 1

2
Rationale 1: Urinary frequency is common during the last months of pregnancy as the uterus places pressure on the bladder.
Rationale 2: The absence or change in fetal movement can signal a problem with the pregnancy. When no fetal movement has been noted in the past 8 hours, there are fewer than 10 movements in 12 hours, there is a change in the usual pattern of movements, or a sudden increase in violent fetal movements followed by a complete cessation of movement, further investigation is warranted. Immediate evaluation of the fetus should take place.
Rationale 3: Pregnant women begin to produce and secrete colostrum from the breast during pregnancy.
Rationale 4: Tylenol (acetaminophen) is appropriate for the back pain that accompanies third trimester pregnancy.