A 28-year-old gravida 1, para 0 client who is at term calls the labor and birth unit stating that she thinks she is in labor. She states that she does have some vaginal discharge and feels wet but it is not bloody in nature. She relates a contraction pattern that is irregular, ranging from 5 to 7 minutes and lasting 30 seconds. What questions would be used during the process of phone triage by the nurse? (Select all that apply.)
A) Ask her if her if she thinks that her membranes have ruptured.
B) Ask her if she has any evidence of bloody show.
C) Have her keep monitoring her contraction pattern and call you back if they become more regular.
D) Ask her when her she has her next scheduled visit with her health care provider.
E) Tell her to come into the hospital for evaluation.

Question

Quizplus · Accepted Answer

The cornerstone of obstetric triage is reassurance of maternal-fetal well-being. Thus, in view of the assessment data that the client provided, the nurse should ascertain membrane status and ask the client to come in for evaluation. The client has already indicated that the vaginal discharge was not bloody in nature. Having the client continue to monitor at home would not provide assurance of maternal-fetal well-being. Asking the client about the next scheduled physician visit does not address current health concerns of impending labor.

A 28-Year-Old Gravida 1, Para 0 Client Who Is at Term